i '111 I '@ I # @ i(EO(')Ii@ '17i f !'limit opililt 'i"lifillilj"! f 1 McLaughlin I DEPARTMENT OF HEALTH, EDUCATIONP AND WELFARE CR2219 2 PUBLIC HEALTH SERVICE 3 HEALTH RESOURCES ADMINISTRATION 4 ROCKVILLE, MARYLAND 5 6 Thirtieth Meeting of the 7 NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGR MS 8 9 10 Conference Room G PArklawn Building 11 Ed kville, Maryland c Tuesday, July 17, 1973 12 The meeting was conven@-4a@,.,9:07 am., p 13 Dr# H. B. Pahl, Acting Director, Regional Medical Program 14 Service, presiding. 15 COUNCIL MEMBERS PRESENT: 16 17 "IMrs. Audrey M. Mars @,, Dr. George E. Schreiner 'Z,,Mr. Edwin C. Hiroto 18 Dr. Paul Haber (for Dr. Marc J. Musser) Dr. John P. Merrill@ 19 Dr. Alton Ochsrier 20. Dr. Alexander M. MdPhedraft 17 Mrs.-Mariel S. Morgan Dr. Ru sell B. Roth 21 i.( D " Benjamin W. Watkins@' Ur4 Sewall Oi Milliken 22 ALSO PRESENT., 23 Dr. Robert van Hoek 24 Dr. Robert Laur Mr. Robert Chambliss 25 Dr. Paul Teschan (cont'd) 2 ALSO PRESENT (continu6d): 2 Dr. Harold Marguli6s Mrs. Judith Silsbee 3 Mr. Jerry Gardell Mr. VAn NostrAnd 4 Mr. Kpnneth Baum 5 And others @6 7 8 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 3 C 0 N T B N T S 2 Agenda Item @e 3 Call to Order and Opening Remarks 4 4 Consideration of Minutes of February 7, 1973 Council 10 5 Report by Dr. Pahl, Acting Director, RMPS 11 6 Overview of Legislative Chronology 26 7 Overview of Phaseout 8 Mrs. Silsbee 39 9 Mr. Gardell 51 10 Mr. Chambliss 60 11 Presentation by Dr. Paul Teschan for Coordinators 67 12 Remarks by Dr. Robert J. Laur and Related Discussion so 13 'Remarks by Dr. Robert Van Hoek 144 14 Consideration of Future Meeting Dates 140 15 Resolution re Construction Authority 15 16 Resolution Endorsing Adjusted Budg6t Periods and 17 Approved Support Levels for S. and Delegating to the Director, RMPS, Limited Authority for 18 Making Similar Future Adjustments 159 19 Discussion of Statement Submitted by Coordinators 17 186 20 Discussion of Development of Criteria and Application 21 Other Business 190 22 23 24 25 4 P R 0 C E B D I N G S ----------- 2 DR. PAHL: The meeting will now come to order- 3 1 have been waiting a few minutes because *6 do expect to have 4 Dr. Roth here. Dr. Margulies although not officially 5 connected with the program, is on h a way, and I'm §ur you 6 wish to see him, And we also expect to have Dr. Merrill 7 appear a little bit later this morning en route from out of 8 town. 9 Before getting into our agenda, I would like to 1-0 welcome each of you personally and officially back to the 11 council ta-ble 4 circumstance which perhaps some of us did 12 not expect to see happen at least during a portion of the 13 year. 14 We Are very glad to have the opportunity to meet 15 with you particularly during *hat I@ am sure is a very busy 16 summer period for all of us, and we feel 16ttunatO that 17 you have b6en@able to arrange your schedules to be with ba. We have a rather full day, and the staff has 19 worked Very hard in preparation tot the Council and so 20 with your permission, I will move Along and try to indicate 21 to you, after we get through some of the general announce- 22 ments whit the plan of the day is and what we hope to 23 accomplish. 24 We did indicate that we would like to have you 25 feel free to depart early afternoon, but, of course, if the 5 I- discussion continues on, we would be very pleased to stay 2 as long as you feel it is important to our mutual 3 understanding of the matters at hand. 4 Now first I would like to welcome Dr. Paul .4 PI 5 Hpber, whom I also haven't met but who is sitting in 6 for Dr. Musser from the VOterans Administration. We are 7 pleased to have you here, Dr. Haber. 8 In terms of out general announcements, in the 9 folders under the tab "Agenda Materials" and behind the l@o seating chart there is the usual statement on conflict of interest and the confidentiality of meetings. 1 believe 12 tIhese have been with us in each of our Council meetings. 13 Thusi it is not important to go over them. And, Of 14 course, all of our Council meetings, including this one, are 15 open meetings. 16 17 Dr. Roth, welcome@back to the council table. DR, ROTH: Thank you, DIR@. PAHL: I would like to indicate that Mr. 19 Ogden is unable to attend the,.meetiog this time and sends 20 his regrets and looks forward to working with the staff and 21 the Council in coming months. 22 Dr. Cannon also is unable to attend, although we. 23 had a very long conversation by telephone concerning some of 24 the matters at hand, and he indicated he would be perhaps 25 in touch with some of you conveying his thoughts !bout items I 6 1 vhich undoubtedly would be coming up for attention, and ve 2 vill be glad@to have those comments at the appropriate time. 3 I did intend to make some introdbdtiong, but 4 perhaps,we vil@,,have@to hold those@3off until the parties appear n c 5 Bu@ti let me @@i'@di a"te' vhom We do expect to have 6 presenting items, tq,you today, and,, undoubtedly, the will 7 be here later this morning.. 8 Dr. Robert@Laur vill@be@speakin vith us some" 9 9 where about 11:30, quarter of 12i Dr. Laur is the Acting 10 Administrator of the nev Health Resources Administration and is very active and has been activei of course, in that 12 capacity in the Rekiohal Medical Programs issues And concerns 13 over recent months. 14 And timing couldn't belbottet. Dr. Robert van Hoek l@5 Vill be meeting with us for I hope as much as possible 16 during the course of the meeting and At least after coffee, 17 viil@have a fev remarks to make4 Dr. van Hoek is not only 18 the Program Director of the NiiionAl Center for Health 19 Services Rosoardh and Development and hag mot vith the 20 Coubdil before and presented items of interest, but also is 21 the Acting Director of the nev Bur6iu of Health Services 22 Research and Evaluation vhich has been developed iithin this 23 nev organizationand ve vill be having more to say to yo 24 about that in a tev minutes. 25 We may have some guests from downtown. 7 u will also recognize familiar facts around But yo 2 the All. And of course, the other person I would like to v 3 specifically mention is Dr. Paul Teschgh as the Chairman 4 of the Coordinators' Natibntl St-eering'Committee and 5 Program Director of the Tennessee Mid-$Outh Regional Medical 6 Program, who also will have to be departing early but would 7 like to have An opportunity to present a few comments to 8 you from the Co dinators"point,of view and we *ill make or 9 opportunity for that presentation. 1.0 e4face" sitting next to Paul And the "strang ell (indicating Di. is one that you recognize full W:@ 12 Margulies). I must say it@feels very strange 13 sitting here and having him sitting there, (Laughter) 14 I will have more to say about this as we go@, 15 along. 16 Concerning some housekeeping detailsi some of us 17 will have our first cup of coffee, and some the second cup, 18 about 10-.15. We had scheduled the lunchtime break at 19 approximately 12:30; buti of course, that is subject to 20 how you feel the day is moving along. 21 And Mrs4 Handal in the yellow outfit will be very 22 interested in helping you with plane reservations and any 23 changes that you would like to make. 24 This is an open meeting. We have members of the@ 25 public who are at the appropriate point in the agenda vtlcome 8 to make comments and observations, 2 If any member of the public does wish to address 3 the Council, we would appreciate it if he would identify 4 himself or herself as to name, organization, and the group 5 he represents if other than himself. 6 Now, the plan of the day sounds a little 7 formal, but, in fact, as you know, we have not met since 8 the first week of February, and at least here in Rockville 9 much has been going on, and we would like to take this l@o opportunity primarily to bring you up to date as to what hat been happening from our point of view, and through the Steering Committee chairman we will have what has been 13 happening in the Region al Medical programs from their point 14 of view. 15 Thus, I will have a somewhat brief report to 16 give to you, pointing out certain highlights of activities 17 that wo have been engaged in and some matters that we will 18 be discussing over the day, and following that there will be 19 a report by Mr. Lyman Van Nostrand who is the Chief of 20 our Planning Branch of the Office of planning and EvaluAtion, 21 who will give an overview of the rather complicated budget 22 and legislative chronology, which will bring you up to 23 date as to where we are and how we got here. 24 Following this -- and there are items in the agenda 25 book which will be identified for you by the individual 9 1 speakers -- we will then have a@presentatioh of the overview 2 of the phaseout, and Mr. Chambliss,and Mrs.,Silsbee will 3 describe what we did, how we vent about it, what we see the 4 impact to have'been. 5 Then we will have something concerning the 6 financial aspects, which are rather important, and Mr. Girdtll, 7 who deserves some kind of medal yet unstrtck by the Government 8 for call beyond duty this year, will present to you the 9 overview of vfiat our financial affairs are. Mr. Chambliss 10 will then wind up on a programmatic,note giving you some indication of where the regions are in terms of activities tjat are now going on. 13 We ate certainly far from on out knees. We 14 have been stumbling a bit but I don't believe that we;are beyond repair. And I believe Mr. Chambliss will indicate 16 that to you in his report. 17 We do have today two formal actions that we 18 would like to have you consider and take action ono and 19 these will be the subjedt of handouts. They represent 20 delegations of authority which will become cleat to you as 21 to why we need these delegations of authority in order to 22 manage our affairs during this still somewhat difficult 23 transition period. 24 Then, if we can accomplish most of this by 25 10:15 to 10:30, we will have presentations by Dr. Laur, 10 I- Dr. van Hoek, Dro Teschan, and We may have to rearrange the 2 order in order to accommodate schedules. 3 And then, most importantly, both before and 4 after lunch,6r over the lunch period, depending upon your 5 pleasure, we@@need to discuss very im rtant issues as 6 to vherewe go from here, the kinds of programmatic 7 options which Are under consideration, and some of the 8 review process and procedures which,,we are facing and on which we need your guidance and assistance. 10 So really the first halt of the morning, it you will, is devoted to historical presentations, what 1-2 happened and hov we got here, and then we move into where 13 we go from here. 14 As I say, we sorely need your good advice, coun- 15 sel and participation in doming months. 16 That is our overall plan for the day, and you 17 will be hearing from a number of our staff members. 18 Sin6e Dr. Merrill is not here, let us omit the consideration of future meeting dates, but I will indicate 20 to you we are looking toward a two-dty Council meeting the 21 la$It Week of N6vdmber after Thanksgiving, but I believe it 22 would be better if we held off the actual decision on that 23 until Dr. Merrill is able to arrive. 24 so if we may turn to a consideration of the 25 minutes of the last meeting of the Council, February 7th I I- would ask the Council if there are any corrections to be 2 made in the minutes. And if not, I will receive a motion 3 for approval of the minutes. 4 DR, McPHEDRAN: I move they be approved. 5 MRS. MARS: Second. 6 DR, PAHL: It has been moved and seconded to 7 approve the minutes of the February 7th Council meeting. 8 All in favor say "aye." 9 (Chorus of "ayes.") 10 So moved. I would like now to turn to my report, which I do intend to make fairly brief. We are all on a little 13 bit of a time schedule this morning, and that includes the 14 chairman, and I will try to observe that. ]@5 The most important and singular event which has 16 occurred since we last meet as a Council and staff has, 17 of course, been the departure of Dr. Margulies from the 18 leadership of the program. And I must say again that I 19 find it quite strange to be sitting here with Dr. Margulies 20 on the sidelines. But I am glad even with the press of 21 duties he is able to meet with us today, and I hope he vi 22 be able to meet with us in the future, since we again need 23 his outlook, information and guidance. 24 1 would like to say that from my point of view 25 it often happens -- and I think this is a case in point -- I 12 1. that people tho. ha@ye,served the@@G vetnment very well in a 2 capacity of major responsibility for one reason or another, 3 through reassignments, rea pointment to positions of major p 4 responsibilit seem to drift off from the program and it yp 5 is never quit6 recognized. 6 And I would like to take this opportunity I 7 think to make it a part of our formal record that we 8 note that this is an important event in the life of the 9 Regional Medical Programs and that Dr. Margulies served the 10 program not only as the Acting Director from March of 1970 to December of 1970 but Also, as you know, gave strong leadership as the Director from December of 1970 through 13 June 17th of 1973. 14 There is nothing magic about June 17th except I 15 became the Acting Director on June 18th, which happens to be 16 the day the President signed the one-year extension so I 17 believe I revitalized the program, not Dr. Margulies. 1.8 (Laught6r) 19 1 know Dr. Margulies is generally uncomfortable 20 about being on the receiving end of statemetts, but again 21 the staff, because it has been summer and we have beet Very 22 busy in our own respective responsibilities, have not had 23 occasion to get together, and I believe this is an 4 appropriate point to read a statement into the record, a 25 brief statement, which perhaps, I trust, expresses some of I 13 1 the feelings that the staff have concerning@Dr. Margulies' 2 leadership over these years. 3 And so, with your permission, I will read the 4 brief statement. 5 ffOn behalf of all of the staff of the Regional 6 Medical Program Service, both those who are with us this 7 morning and those who are absent or who have departed from 8 the program, I want to take this opportunity publicly to 9 express to you,, Harold, our congratulations and very best 10 wishes as you assume your new duties as Associate Administrator 11 for the Office of Planning, Evaluation and Legislation in 1-2 the Health Resources Administration. 13 "Mor6 importantly, however, I want particularly 14 to express our awareness and deep appreciation for your 15 having set a high standard of excellence in which WO have 16 taken great pride throughout your several years as the 17 Director of the Program. 18 "We note here for all to witness, particularly in 19 these troubled days of our country, the strength you have 20 afforded to all because of your personal integrity and 21 your selfless dedication to the highest principles of 22 public interest And to working in the public interest thoug 23 at times this has been at personal cost. 24 "As your staff we have benefited too from your 25 belief in the worth of each person as an individual and the 14 1 need to work for the betterment of that person, and nowhere 2 is this better exemplified than in your personal and 3 official commitment to the principle and program of pro- 4 viding equal opportunity both within the Regional Medical 5 Program Service and the Regional Medical Programs for a 6 persons regardless of race, sex, or other circumstances 7 which may compromise such opportunity, 8 "Haro,,Id,,it has been A rewarding experience for 9 each of us to have worked together with you in the Regional 10 Medical Program Service toward a worthwhile goal, improving 11 the health of all of our people. We wish you our best in I your new endeavors," (Applause) 14 DR. McPHEDRAN: Dr. Paul, may I add something 15 to that? 16 DR. PAHL: Dr. McPhedran. 17 DR. McPHEDRAN: I want to add my thanks, Harold. 18 You have been a great help in our search for ways to 19 insure quality medical care for everyone. It has been a 20 pleasure for the same reasons given by Herbert Pahl. I 21 have appreciated your literate speaking and writing, but, 22 more than that, your friendliness and consideration for 23 others which informs all of your work. '24 1 am pleased to learn that you Will continue in 25 that same kind of effort. 15 DR* PAHL** Thank you, Dr. McPhedran. And I know 2 I speak for all the members of the Council in having these 3 statements recorded in the official record of this Council 4 meeting. 5 You didn't expect this, I know, and,so you may 6 now leave for vacation "- or I guess it's tomorrow you leave 7 for vacation. (Laughter) 8 Turning back to our report, which seems a little 9 less of interest to me right at the moment, but, nonetheless, 'O let me pursue the agenda I set for myself. lwould like to indicate, first of all, what is the status of our Council. Unfortunately, I have to 13 relate that Dr. Gerhard Meyer has resigned, with his 14 regrets, by letter, most recently, as a result of the press 15 of business, And so I believe this leaves us, Ken, with seven 16 or eight -- 17 MR, BAUM: It leaves us I think with seven 18 vacancies. 19 DR. PAHL: Seven Council Vacancies. Of course, 20 nominations had been in for the Council this past spring, 21 and all of that was held in abeyance because of the proposed 22 termination of the program4 23 So we do hope to have our Council up to full @)4 strength in coming months, but I also have to indicate to 2,5 you that five of those sitting around the table have terms 16 I expiring this November@ 30th, and'we will'be most fortunate 2 indeed if we can arrange matters to have all of you with us 3 beyond that point in time, and we will be working toward 4 that end with your permission. 5 Our Review Committee, as the next topic, no longer 6 exists. As you,may know, there is a general interest 7 within the Government, and certainly within DHEW, to reduce the 8 number of advisory groups to the extent that the Government's 9 business may still be conducted without undue detriment. 10 In addition to that, with the phaseout of the 11 program, we had no choice but to have the Review Committee 12 as an established committee submitted to the Department for 13 termination June 30th. And with the efficiency which 14 the Department does sometimes show, these papers were 1,5 processed somewhat prior to June 18th, and so we find 16 ourselves at this point in time with no Review Committee. 17 To reestablish a Review Committee represents a 18 certain lag in time due to procedures one must go through, 19 so as a Council and staff we stand together and alone, 20 and this will have A bearing on some of the matters that we 21 discuss this afternoon concerning how we conduct our 22 affairs over coming months, because our primary responsibility 23 of course, is to not only support but revitalize the 24 regions, and we must do this under somewhat strained circum- 25 stances. 17 I would like to indicate for those of you who 2 are not aware that the chairman of our former Review 3 Committee, Dr. Schmidt, is now the Commissioner of Food and 4 Drug Administration, so we do have the opportunity to 5 pass in the halls and oh the elevator but we don't see him 6 in connection with Regional Medical Programs business. 7 Now I@@would like.to turn to a brief review 8 of the various organizational changes that have taken 9 place since we met. We have these in your folder, but I would 10 ask you not particularly to turn to them since we have 11 vu-graphs. But under "Organizational Charts" you will be 12 1 able at your leisure to study what all these new boxes are. 13 1 gut I would like, if I might at this point, to 14 run through rather quickly for you with vu-graphs these 15 changes, And we will hope that this shows what the new 16 17 structure of the health part of the Department looks like. (Slide) 18 I hope all of you can see this. Can you hear me? 19 The organization of the health agencies is, of 20 course, under the Secretary of HEW, Mr. Caspar Weinberger, 21 and Under Secretary Frank Carlucci. The Assistant Secretary 22 23 for Health is Dr. Charles Edwards. Under Dr. Edwards there is the National Institutes 24 of Health under Dr. Stone, the Center for Disease Control 25 under Dr. Sencer, Food and Drug Administration under our 18 I- former chairman of the Review Committee, Dr. Schmidt, t e 2 Health Services Administration under Mr. Harold Buzzell, 3 and the Health Resources Administration, the administration 4 that we are located with, under Dr. Robert Laur w o will be addressing us later this morning. 6 The Health Services and Mental Health Administra- 7 tion under Dr. Verne Wilson, therefore, has been broken 8 into three units, the Center for Disease Control, the Healt 9 Services Administration, and the Health Resources Administra- 10 tion. In addition to that, the Bureau of Health Man- 1-2 power Education and certain other activities have been 13 brought into one or another of these units. 14 This how constitutes the set of agencies and 15 responsibilities that Dr. Edwards has. 16 May I have the next vu-graph9 17 (SlidO) 18 Now, turning to Dr. Edwards' office, the Deputy 19 Assistant Secretary is Dr. Henry Simmons, and, of course, 20 the Executive Offide is under Rupert Moure. 21 Health Planning and Program Evaluation is under 22 Beverlee Myers, who was with Dr. Wilson in HSMRA. 23 Program Operations, Lionel Bernstein, 24 Policy Analysis and Research, Daniel Zwick. 25 Regional Or.erations, Mr. Kelso. 19 Administrative Management under John Droke. 2 Beverlee Myers, having been in HSMHA Andworked 3 very closely with RMPS in past years, of course, understands 4 the program and I think will be a wonderful liaison to have 5 in this new position. 6 The next chart, please. 7 (Slide) 8 Now, turning to the Health Services Administra- 9 tion, the Administrator is Mr. Harold Buzzell, and there 10 is a Program Planning, Evaluation and Legislation Office 11 and Administrative Management. But the programmatic areas are the Indian Health Service, the Federal Health Programs 13 Service, the Bureau of Community Health Services under 14 Dr. Paul Batalden, and the Bureau of Quality Assurance 15 under Mike Goran, which includes the PSRO, Utilization 16 Review Medical Review, and Independent Professional 17 Review. 18 Again, these charts are in your book. t is a 19 lot of information and new titles. You can study them at your 20 leisure. 21 The next chart, please. 22 (Slide) 23 We now turn to the organization where we are 24 located, the Health Resources Administration. These are 25 all acting appointments at the moment. The Acting d 20 1 Administrator is Dr. Robert Laur. 2 Public Affairs, Mr. Lebow. 3 Planning, Evaluation and Legislation, Dr. 4 Margulies. 5 Administrative Management, Mr. Parks. 6 Programitidally, the Administration has been 7 constructed along the lines of three major bureaus. The 8 one bureau, the National Center for Health Statistics, under 9 Dr. Perrin, has a major responsibility for aggregating 1.0 all of those kinds of functions in which generalized 11 information and statistics are sought from various programs. 13 So it does include the National Center and 14 also the Bureau of Health Manpower Education's Medical 15 Intelligence Division -- is that it, Harold? -- 1 6 DR. MARGULIES: Yes. 17 DR. PAHL: -- and other units. And this also 18 has the Federal, State, local cooperative health data 19 system. 20 The Bureau that we are located in is the Bureau 21 of Health Services Research and Evaluation under Dr. van 22 Hoek, and later this morning he will perhaps have a few 23 words to say about the proposed organization of this. 24 But it does consist of Dr. van Hoek's current program 25 responsibility, the National Center for Health Services 21 11 Research and Development, together with the Emergency 2 Medical Services activities of what was USMHA, and the 3 Regional Medical Program Service. 4 I will say more of this in just a moment. 5 But to give you the third bureau, it is the 6 Bureau of Health Resources Development under Dr. Ken Endicott 7 of the Bureau of Health Manpower Education and consists 8 of the Bureau of Health Manpower Education under Dr. 9 Peter Eidhman, Comprehensive Health Planning Service 10 under Mr. Robert Jahes, and the Health Care Facilities Service under Dr. Harald Graning. 1 2 1 All of the bureaus are currently organizing 13 themselves and will be submitting proposed plans of I 14 organization over the course of the summer, and again Dr. 15 van Hoek perhaps will be interested in giving you a timetable 16 for this. 1.7 I think the point is that we are in the bureau 18 which includes both the Emergency Medical Service system 1 9 and the R & D activities. 20 1 made a note for,myself,that it's interesting 21 to me that within the six-month period --land I hope this 22 is not a prognosis by any.means that we have had at the 23 Administrator level of the agency in which I find at least 9@4 myself working Drs. Wilson, Sencer,@ Mr. Buzzell, and Dr. 25 Laur. And so if sometimes the policies from Washington seem 22 to be changing and directions move a little differently, 2 you will see that this rapid turnover of top management 3 undoubtedly is partly responsible, and we continue to 4 suffer to a certain extent certainly within the health area 5 in the fact that certain key positions are not filled at 6 all and certain major positions turn over rather frequently. 7 We do not at the moment have a full-time 8 permanent Administrator of the Health Resources Administra- 9 tion, but this is probably true across Government from w a 10 I can understand, but it does make a difference in how 11 wellwe can act, ]@2 Now I would like to turn to the staffing of 13 our own Regional Medical Program Service -- 14 (Slide 15 -- and indicate to you where we are, where we 16 were before we engaged in the phaseout process which i 17 applied to the Regional Medical Program Service itself, of 18 course, not just to the Regional Medical Programs. 19 And without trying to make too much of the 20 numbers, we have looked at the professional people on 21 board in January --.at January 1 -- and at July 1 and 22 our clerical and supporting staff January I and July 1 by 23 office. 24 First of all, the totals. We did have 234 People 25 in January. We are now down to 128 people. 23 We had 125 professionals. We are down to 84. 2 We had 109 supporting personnel, and we are down 3 to 44. 4 This should indicate that we have been going 5 through the same kind of personnel loss that the Regional 6 Medical Programs have. 7 There has been within the Government a RIF, a 8 reduction in force program, which has a planned program for 9 us for a reduced number by September 30 and March 31, so 10 that if the personnel continue to depart -- which we believe 11 is no longer necessary with the extension of the program -- 12 we would have been down to perhaps 70 people by September 13 30 and 30 people by March 31 and 9 people by the end of the 14 year. 15 I would like to take just one moment and publicly I (i 17 again thank-" The staff knows full well what has happened here in recent months. But Mr. Charles Hilsenroth, who is has been our Assistant Administrator or Director for the 19 Administrative Management and Services of the Regional 20 Medical Programs, has done an outstanding job. 21 I think only those of you who have worked in the 22 public service know how difficult it is sometimes to 23 rearrange transfers of personnel and to locate opportunities 24 for personnel as they move out of a program into other 25 areas, and without question Mr. Hilsenroth, who retired last 24 month, has done an outstanding job in relocating our 2 personnel, the kind that you see have been lost from each 3 and every office. 4 1 think due recognition of this was made, but 5 it should be also a matter of record here. 6 Now, the numbers themselves, either in the 7 professional category or the clerical category, don't really 8 indicate what has happened. As you know from being with 9 many organizations yourselves, it is who leaves, the 10 timing, and, of course, the morale problem. And so we find at the moment that we have key people in each office 12 who have left. 1,3 And it would be somewhat I guess not necessary 14 really for me to indicate to you, but the fact that Dr. 15 Hinman is sitting over there, the fact that Dr. Margulies 16 is sitting there, the fact that we have people from the 17 Office of Planning and Evaluation, Systems Management, 18 this office is leaderless (indicating Office of Communications 19 and Public Information)-- And we can go down and down. 20 So we have been working against a difficult set 21 of circumstances and continue to do so. We Are trying to 22 23 stabilize and move ahead. And to the 6xtent that the Agency is reorganized and the Bureau is reorganizing this has 24 posed or superimposed a set of problems which we continue to 25 deal with. 25 1 1 would like to turn to the other topic of the 2 overall picture of our budget. 3 (Slide) 4 This chart is in the book. I wontt spend too much 5 time on it. The original budget request for fiscal 1973 6 'Was $131 million. The amount in the appropriation bills for 7 1973, which was vetoed, is $164 million. 8 We roughly spent $59 million in 1973, and Mr. 9 Gardell again will receive a commendation because out of 10 that we ended up with a balance of $2,449, which is again 11 an unusual circumstance particularly with the ways in which 12 the program has been going recently. 13 The authorization for fiscal 1974 is $159.6 14 million, and the continuing resolution under which we 15 operate at the present time for fiscal 1974-- We might as 16, well indicate it's either $60 or $81 million, and itts 17 an academic point at this time because of matters which have 18 moved the whole process somewhat further along. 19 I think that's all we need from the vu-graph. 20 Now, I'm taking more time than I should, and I 21 know the staff is nervous. On the other hand, I think 22 itts important that you realize some of the positions that we 23 have been in. 24 1 would like to terminate my portion of this 25 presentation and then turn it over to Mr. Van Nostrand to 26 1 go over the budget and legislative overview by saying 2 that the WASHINGTON POST today -- they must have been 3 psychic -- recognized the position that the Regional Medical 4 Programs have been in. And I'm very happy to say that those 5 of you who got up early enough and got past the front 6 page and that rather startling series of things may have 7 gotten to see on the comic page where Charles Schulz 8 finally recognized the Regional Medical Program Service's 9 problems and expressed the philosophy perhaps that the 10 staff has had to adopt over recent months. 11 It's a four-picture comic strip, and Peanuts 12 is saying, with his face in his hands, "I used to try to 13 take each day as it came -- you know, live one day at a Itm down to half a day 14 time. My philosophy has changed. 15 at a time." (Laughter) 16 I'd like to indicate I think wetre out of a half 17 a day at a time and we're back at least to the one day. 18 And I think with this Council meeting wetre beginning to 19 look at weekly, monthly, and possibly even the full fiscal 20 year. 21 With that I'd like to have Lyman come and address 22 you oh the budget And legislative chronology. 23 MR. VAN NOSTRAND@. As Dr. Pahl has said, you 24 could call this year almost the fall and rise of RMP, 25 although the novel isntt quite fihi0hed yet. 27 1 It really started back in 1972, the Presidential 2 budget for FY 73. The figure that was proposed was $130.3 3 million. During the appropriations process, the bills 4 that came through were quite a bit higher across the board, 5 not only for RMP but for all of HEW. 6 In the case of RMP, the figure that they came up 7 with was $164.5 million, which was some $34 million over 8 the Presldent's budget. 9 Because both the HEW appropriation packages were 10 so high, the President vetoed both of those. 11 This forced us to go into the situation of a 12 continuing resolution. The figure that was picked for 13 this was the lower of the House and the Senate appropriations. 14 Since the House figure was $150 million, that was the 15 figure that became our sort of current rate. 16 In January 1973 the President released the FY 74 17 budget, and this was, of course, where they made the major 18 decision to propose termination of RMP in FY 74. At the 19 same time they put in an amended 1973 level budget which 20 was for the amount of $55.4 million. 21 When they proposed the termination of RMP, they 22 gave what they considered a rationale behind this. They 23 said that the program had been going for eight years, had 24 spent about $500 million. They felt the program had never 25 really established a clear focus for itself. It had been 28 1 part of the time on heart disease, cancer and stroke, 2 moved into comprehensive care delivery systems. 3 Another problem they found with the program was Is 4 that they felt too much money was being spent on the core 5 staffs. Over the past few years this has averaged about 40 6 percent, and there was some problem with this. 7 There was some feeling that too many funds had 8 been going into training and continuing education, with the 9 belief that this kind of thing could have been picked up 10 by physicians, nurses on their own, on their own salaries, 11 hospital costs, and so forth. 12 And there was some dispute too in terms of@. Had 13 RMP really gotten the latest advances out into the system? 14 There was some question about this. Could It really be 15 proved? 16 An additional rationale was that there were a 17 number of now health programs that hid come along that 18 could pick up some of the functions RMP had in the past, 19 The idea was that planning functions could be done by the 20 Comprehensive Health Planning agencies, that the Professional 21 Standards Revi6v Organizations could pick up on the quality 29, of care aspects of health care. NTH was doing more in the 23 way of heart disease and cancer control programs and that 24 they could pick up some of the things that RMP had been 25 doing. 29 1 And also that probably another very big piece, 2 with the passage of the social security amendments last 3 year that included reimbursement for kidney disease-- The fA 4 idea was that with Medicare paying for kidney disease, a lot 5 of the work RMP had been doing In this area probably wouldntt 6 have to be continued. 7 On March 8th, the first evidence of some 8 congressional opposition to this proposal was evidenced 9 when Senator Kennedy introduced, with 15 of the 16 members of 10 the Labor And Public Welfare Committee, a one-year 11 extension of 12 of the Public Health Service authorities. 12 This included RMP as well as a number of others, including 13 Hill-Burton Community Mental Health Centers, R & Do 14 Health Statistics, Allied Health Training, a whole broad 15 range of programs. 16 The level of authorization that they put In there 17 was the same as it had been in the previous RMP authoriza- 18 tion, $250 million. 19 The basic rationale of why they were calling 20 @for aone-yetr extension was that the committee felt they 21 had not had enough time to review these programs, that the 22 budget had proposed phaseout in such a quick period of 23 time they really hadn.1t had time to go over and see what 24 the strengths and faults of the program were, what changes 25 needed to be made to modify it so it was a little more I 30 1 productive. 2 On March 14th an extension bill was also intro- 3 duced in the House, H. R. 5608. This was Representative Is 4 Hastings along with the entire Subcommittee on Public Health 5 and Environment. 6 The first hearings were March 22nd in the Senate. 7 That was a one-day hearing after which the bill was reported 8 out. And a few days later, on March 27th, the Senate 9 passed the bill by a vote of 72 to 19. 10 This was followed with hearings in March, March 11 use. Alo 27 through 29,and again on May 8, in the Ho ng with 12 the Administration testimony, there were also the RMP 13 coordinators and a panel of RMP hysicians that were on RAGs p 14 around the country, and they presented evieence that they 15 thought was contrary to the point of view being expressed 16 by the Administration. 17 They talked about some of the accomplishments RMP 18 had had. They admitted there were some problems in certain 19 areas, that there could have been more focus on certain 20 problems, but they thought the overall record was generally 21 favorable around the country. 22 On May 15th, H. R. 7806 was substituted for the 23 first House Version, the idea being to lower the total 24 authorization levels in there by over a billion dollars 25 so there would be less reason to cite vetoing it in terms of 31 1 budget-busting. 2 Because of that, the RMP authorization was dropped 3 from a level of $250 million to $159 million. 4 On May 31, the House passed this bill by a vote 5 of 372 to 1. 6 On June 5 the Senate decided to drop its original 7 version of the bill which had the $250 million for RMP 8 and accept the House version, I think on the assumption that 9 it had a better chance of being signed by the President, 10 and that was passed by a vote of 94 to 0. 11 -Z So, in essence the bill went to the President 12 with really only one vote against it. It was passed 13 unanimously in the Senate and 372 to 1 in the House. And 14 the President signed the bill on June 18th. 15 In his signing message he said that he realized, 16 you know-- He acknowledged the opposition they had had to 17 the passage of this but he said he felt if the Congress 18 had one year to look over these programs and recodify and 19 consolidate, they might be able to come up with a better 20 package, how to authorize some of the authorities under the 2 1 Public Health Service law. 22 Once we had the authorization, the next step in 23 this process, of course,, was t,o'@get appropriation, the 24 actual funds. There have been both House and Senate he@arings 25 over the last couple of months. 32 1 The first real action on this was the House 2 passage of the FY 1974 appropriation bill. That included 3 a figure of $81.935 million for RMP. The Senate is Is 4 still holding hearings on the 1974 appropriation. If they 5 follow their usual form, they will come up with a figure 6 higher than that,which leads to the problem again that if 7 the HEW appropriation is too high -- again the House version 8 is already a billion over -- will this lead to another 9 veto? And so that is something that has to be looked out 10 for down the Pike. At the same time, because the Senate had not 12 finished its work on the appropriation, it rdquired the 13 signing of a continuing resolution. This allows us to 14 spend through September 30th, and the rate at which we are 15 allowed to'spend is the lower of the House version or 16 last yearts continuing resolution. 17 ,@Since last yearts was $150 million and this 18 yearts is $82 million -- the House version for FY 74 is 19 $82 million our current rate at least for this purpose 20 is $82 million, at least according to the congressional 21 interpretation. 22 At the same time, at the end of PY 73, a supple- 23 mental appropriation bill was passed. This is something 24 that happens almost every year. The Executive Branch sends 25 in all the last-minute items that have seemed to have 33 1 occurred In the budget, expenses that were not really known 2 in advance. 3 That budget was sent to the Senate and the House. 4 The House added $12 million under Section 304 and Title IX 5 of the Public Health Service Act -- which is the RMP 6 authorization -- for construction for D. C. Childrents 7 Hospital here in D. C. 8 At the same time, the Senate both in committee and 9 outside, in the floor debate, added the $12 million for 10 D. C. Childronts, added $4.5 million for construction of 11 a children's center In the northwestern part of the United 12 States, very probably in the State of WaOhington, and 13 $500,000 for completion of a hospital up in Vermont which 14 Senator Aiken had added on to the proposal. 15 So the bill as passed -- and the President signed 16 it this was after the negotiations on the Cambodian 17 resolution includes $17 million that is available until @8 expended under Section 304,@l, which is the RMP authorization, 19 for construction of these three projects that I have men- 20 tion4d. 21 Dr. Pahl I guess will be speaking to you later 22 about those in terms of delegations of authority of how we 23 are going to handle those. 24 The only other thing I thought T might mention 25 quickly In terms of other legislation that is sort of coming 34 I along the pike is in terms of the HMO bill. The Senate 2 passed that on May 15th with a total authorization of 3 $885 million for three years. The House Is working on the 4 bill,l think this week, H. R. 51. They expect to have a 5 markup I think this week, which would mean it would be 6 reported shortly thereafter. 7 That is expected to have much lower authorization 8 levels than the Senate version, more in the version of a 9 demonstration grant program. 10 The other bill that is moving along fairly well is the @rgency Medical Services bill. That passed the 12 Senate on May 15th, the House on May 31st. The conference 13 report was reported out July 10th, which essentially put 14 money into planning, feasibility stud es, establishment and 15 initial operations, research in emergency medicine, and 16 training grants. And that was for $185 million for three 17 years. 18 And the only other thing with that which may 19 cause some problem is the fact that the eight Public Health 20 Service Hospitals were added as an amendment to keep these 21 open, which is being opposed by the Administration. So 22 that may or may not cause a problem. Itts hard to tell at 23 this point. 24 A third piece I thought I would mention is the 25 kidney disease part of the social security amendments of 35 1 1972. The reimbursement, for Medicare, began on July 1, 2 1973, and interim regulations on how this was to be worked 3 out were put in the FEDERAL REGISTER on June 29th, essentially 4 saying that for the time being, until final regulations are 5 done, they will continue paying through the normal Medicare 6 channels for hospitals that have already been doing such 7 kidney operations, dialysis, and so on, and that as the 8 program gets going, within six months to a year, they will 9 probably have final regulations that set up what the final 10 procedures are going to be. 1 1 DR. PAHL4. Thank you very much, Lyman. 12 We have given you a good bit of information in 13 both my report and Lymants, and I think we might ask whether 14 you have any questions or points to make or observations 15 as a result of these presentations before we move on. 16 In this connection, I would like to again indicate 1 7 to you that in your agenda books, which I hope you will-" 18 Pardon me. Dr. Schreiner? 19 DR. SCHREINER: When you originally introduced 20 thisi you mentioned a continuing level of either $60 or 21 ,$80 millidn,@and I don't.understand where the $60 million 22 came "from. 23 DR. PAHL@. There hits been a debate going on as to 24 whether the continuing resolution from the Department's 25 point of@viev would be at the current operating level of the 36 1 program or whether the congressional, $82 million House 2 allowance, would be the level of the continuing resolution. 3 And this has been a matter of great internal 4 interest within the bureaucracy. At the moment, as have 5 indicated, this is not of major import because we will be 6 taking up this afternoon the actual funding and fiscal situa- 7 tion of the program, so that at the moment we are not privi- 8 leged to be expending at either of those levels. 9 So although it is of still great academic interest, 10 I believe we'll accept the congressional level of $82 11 million as being at least the lover figure which we can 12 expect from the Congress, and then leave it to OMB and the 13 Department to decide what the funding level of the program 14 may be, looking hopefully, of course, toward full 15 authorization and release of all the funds that are made 16 available. 17 But it's an internal kind of consideration of 18 continuing resolution levels, and the lawyers have had a 19 wonderful time trying to decide just what the continuing 20 resolution means. 21 If you read the legislation and the report, you 22 will also find that the Congress has tried to make very 23 clear from their point of view what they believe the Ad- 24 ministration should consider to be the continuing reso ut on 25 level. 37 1 Yes, Dr. Haber? 2 DR. HABER@. Previously you mentioned one of the 3 criticisms of the Regional Medical Programs was too much 4 money had been put into core staff. I don't understand how 5 that is a criticism. Can you elaborate on it? 6 DR. PAHL@. Lyman, do you want to, or shall I? 7 MR. VAN NOSTRAND4* Essentially what they were 8 saying I think is that some of the activities-- They tended 9 to equate core staff with administrative costs, which Is 10 not necessarily the case. 11 DR. HABER@. That's what I mean. 12 MR. VAN NOSTRAND@* The idea was the money could 13 have gone into direct operational projects rather than into 14 program staff. I think when the coordinators presented 15 their testimony they tried to,shdv that the administrative 16 ut 7, 8 'costs at least in their definition amounted to ab6 17 or 10 percent and that the activities carried ou 18 @by the program siaff'vtre really as good as the operational 19 projects in terms of getting something done. 20 So it's really a matter of their view of how you 21 define what core staff is doing. 22 DR. PARL@. It has been looked at as a very 23 high overhead, when, in fact, it constitutes very important 24 programmatic activities included in that figure. There 25 has been a good bit of misunderstanding as to just what that I includes, and we have tried to clarify it. 2 1 would itdicate in the agenda books that under 3 the various tabs again we have the Xeroxed charts of all 4 those which have beet presented to you through the vu-graphs. 5 Also there is a more detailed legislative chronology, 6 actual excerpts from the congressional hearings and staff 7 relative to the RMP program this year, a section on related 8 legislation. 9 1 believe you will find all of these of value 10 and interest to read a little bit more at your leisure. If we may turn over to the next item on the 12 agenda, which Is the overview of the phaseout, we have 13 asked Mrs. Silsbee, Mr. Gardell and Mr. Chambliss to 14 give to you-- And I would believe perhaps we could accomplish 15 this in a half hour. I have eaten up a little too much 16 time. But I believe that might be about an appropriate time 17 to give you a picture of what really has happened from 18 the period when we last met in terms of administrative 19 actions and where we stand. 20 Just by way of introduction, since you all know 21 Mrs. Silsbee, I would like to say she ver graciously has y 22 accepted, and I am pleased to announce to the Codn6il, 23 appointment as Acting Director of the Division of Operations, 24 having formerly served as the Deputy Director of that 25 Division, and, likewise, Mr. Chambliss has graciously 39 1 accepted to serve as the Acting Deputy Director to me for 2 the Regional Medical Program Service, having served as the 3 Director of the Division of Operations. 4 And so, you see, it's the domino game of everyone 5 moving upward into better jobs, bigger titles, greater 6 responsibilities. And we are really pleased that they 7 take on these responsibilities for us. 8 Judy. 9 MRS. SILSBEE: Well, when Council met last time, 10 we had had the first step in the phaseout, and I believe you 11 had just received copies of the February 1 telegram which 12 vent to the Regional Medical Programs explaining that the 13 phaseout would have to occur and that we would need 14 applications putting forth their plans. 15 The telegram stated the criteria which would be 16 used to review the phaseout plans, stating that during the 17 phaseout only activities that had a short-term impact 18 that we could note would be considered or that had an 19 opportunity to be picked up from other sources and needed 20 some additional time in order to accomplish that fact. 21 We sent the telegram on February 1. And since 22 apparently in the Department of HEW no one had ever phased 23 out a program in any orderly fashion before, we had to 24 start from scratch. We had to develop instructions. We ha 25 to think of the kind of information that the Regional 40 1 Medical Programs would need in order to do this in an 2 orderly fashion, and, knowing that the Regional Medical 3 Programs is an unusual grant program, In that it involves a Is 4 number of different organizations, not only the grantee but 5 all the affiliates, this was our major consideration. How 6 could we do this in a way that would be helpful to the Regional 7 Medical Programs under very stressful conditions? 8 So it took us a while. And I think Jerry Gardell's 9 staff does need a hosanna here, because from the grants 10 management.standpoint they had to develop this materla from scratch. 12 The instructions went out sometime in the latter 13 part of February, and the applications were expected back 14 on March 15th. At the same time we had promised by April 15 15th to give a re @ nse so that they would-- Again looking 16 at June 30th as a first part of the phaseout February 14th 17 the end point, this would give the Regional Medical Programs 18 time enough to do with all of their various organizations 19 what they had to do in order to have an orderly phaseout, 20 Well, we received the applications, and they 21 came in-- I think it was probably a first in the history of 22 Regional Medical Programs. Just about every one of them 23 made the deadline of March 15th. 24 And the applications as a whole were very well 25 organized. The Regional Medical Programs under tremendous 41 1 stress of time and decisions did a beautiful job of present- 2 ing their plans. 3 The applications broke out into various categories. 4 There were programs that had decided to essentially phase 5 everything out June 30th. There were those that had done a 6 pretty stringent veeding-out job at the regional level and 7 were recommending projects based on our two criteria and 8 providing the documentation. There were those that were 9 trying to keep the program staff intact, because the 10 program staffs in certain regions, As Dr. Pahl mentioned 11 earlier, some program staffs, do a series of studies, and 12 so forth, were the vital part of the program, and they had 13 used small amounts of money for studies, and so forth, in 14 order to make the program go. And then there were those 15 Regional MedicAl Programs that wanted to keep everything 1 6 @going pretty much.. 17 We had no experience In reviewing phaseout plans, 18 but we did have some understanding of what the Department 19 expected In terms of phaseout and *by they had allowed 20 this extra time, because there had been one consideration 21- of June 30th -- period. They were interested in allowing 22 some projects meeting these two criteria to go on. 23 So that had to be our major cue in looking at 24 the applications, looking at the projects, to see whether 25 they met one criterion or another, and then to see if they 42 I had the documentation that went along with it, and then to 2 develop the program staff, minimal program staff, that was 3 needed to monitor those projects and phase out the program. 4 The review of the 56 applications was done under 5 very intensive circumstances. We decided very early on we 6 couldn't do a gradual review as we usually do, with the 7 staff looking at it and then coming up and recommendations 8 being made that way, because we were having to do it and 9 make our own ground rules as we went along and then go back 10 to staff information. 11 So aside from a few forays to the emergency 12 medical clinic on my part and to the hospital on Dr. Pahl's 13 part, five of us sat day by day during the day considerin 9 14 these applications, and night by night reading them so we 15 would be ready for the next day. 16 Well, about April Ilth we mete able to send out 17 the telegrams to the regions stating what they could 18 continue beyond June 30th and a level of support that we 19 would allow them. 20 The telegrams also indicated-- Or we knew that 21 there would be appeals, so there had to be appeal review 22 afterwards. And gradually all these decisions were made, 23 and we were ready to phase out. 24 You may be interested in the back of the book 25 under "Phaseout" that the majority of the regions were 43 1 approved to go from June 30th to January or February of 2 1974. About five were approved to phase out June 30th, three 3 of which had opted for that. Is 4 Of the projects that were approved-- And again 5 1 want to emphasize that they had to meet one criterion or the 6 other. Of those projects -- there were about 289 -- of 7 the 289, 209 of then were in the regions that were going 8 on to January or February of 1974. 9 (Slide) 10 In terms of the types of activities that we now 11 find ourselves with before the phaseup again, I did an 12 analysis which could be challenged by practically anyone 13 in terms of the types of projects, and that's in a little 14 vu-graph. But you can always quarrel about how you are going 15 to categorize. But I categorized all of them on the same 16 basis, which are my definitions. 17 As you can see, the majority of those projects 18 ,that were approved,beyond!were'in the area of 19 categorical diseases, or I threw in there specific groups 20 like the neonatal group, and so forth. And emergency 21 medical services about 11 percent. Health manpower, ge era 22 ,which would include our support for the health services edu- 23 cation activities. And health manpower, specific, wh c was 24 for specific professional groups or for specific types of 25 training, including categorical diseases. 44 1 That's all I have. 2 DR. PAHL4* Okay. Are there any questions that 3 you may have concerning this rather brief but I hope 4 interesting view of what the staff tried to accomplish in 5 a rather short time frame and as fairly as possible'? 6 These were professional judgments relative to 7 regions and projects, and, of course, the staff stands to be 8 criticized and have been criticized, but I would merely 9 say that In the circumstances we had to operate, at least 10 from our point of view, we tried to be as fair and 11 equitable as possible and I think only history will 12 record whether this was in fact as good as v6 tried to make 13 it be. 14 Are there any questions? 15 MRS. MARS: What happened to the three that were 16 phased out June 30th? Are they still continuing? 17 MRS. SILSBEE46 Well, actually, there were five 18 that were scheduled to be phased out. But that shows in 19 relationship to our former rating of A, B and C. 20 MRS. MARS: Take the five then. 21 MRS. STLSBEE.I Of the five, once the legislation 22 was extended, two of them which seemed to have enough there 23 to go on requested reconsideration. They had opted 24 originally to go out of business on June 30th. We had no 25 plan B for them. We had a plan A only. So that was the only 45 thing we could consider. And the decision was made to 2 continue those. They had funds that would allow them to do 3 fh 4 it. MRS. MARS@. This was two of them? 5 MRS. SILSBEE@. Two of them. Three of them have 6 been phased out. 7 MRS. MARS@. Completely? 8 MRS. SILSBgE.i Completely. 9 MRS. MARS@. Which ones are they? 10 MRS. SILSBEE4. Delaware, Ohio, and Northeast 11 Ohio. 12 MRS. MS Thank you. 13 M. PAHL Dr. Roth. 14 ROTHI* dent know when o DR.@ r even if it will 15 become appropriate to say more about a document that 16 has been given to me, but this came from the coordinators, 17 and in the first part of it there is a statement that 18 relates to what we have just been talking about on phaseouts 19 Let me ask a question. This saysthat it is 20 believed that the February issuance of phaseout orders 2 1 with subsequent amended awards to each individual Regional 22 Medical Program was in violation of Public Law 91-515 23 because those orders were never approved by this Council. 24 Would you care to react to that? And is it of any 25 Significance if itts true? 46 1 DR. PAHL@O I -feel like perhaps one of the indi- 2 viduals who has been appearing before the Seoate. That's a 3 two-point question. (Laughter) 4 Let me answer the second point first. If true, 5 yes, it is significant. 6 With regard to the first matter, we do hot concur 7 with that position, because as members of the Executiv6 8 Branch we feel that we really must follow what is the 9 Administration's position, and, therefore, when the President 10 did not request support for the program for fiscal 1974 it seemed to us to be a matter of prudent administration to 12 alert, which is what that telegram did -- to alert, all 13 Regional Medical Programs of this fact and to ask them to 14 take those kinds of steps which could lead to an orderly 15 termination and the request, therefore, to submit plans of 16 phaseout. 17 We did not terminate the program with that 18 telegram. I think this is a point which should be under- 19 stood. That telegram was considered to be a matter 20 of administrative necessity in view of the fact that 21 no funds were requested for the continuation of the program. 22 The administrative actions which followed were 23 considered to be that -- administrative actions on the basis 24 of prudent management. 25 The decision to terminate the program, if you 47 will, was a collective decision by the Administration. I'm 2 not enough of a lawyer to know in fact whether this required 3 Council approval or not. But we felt it was a matter solely 4 of management and not a question of Council approval, 5 because this was not seeking advice about programmatic 6 areas or approval of grant funds for the support of activi- 7 ties by the regions. 8 In confirmation of this point of view, I would 9 say that as soon as the President signed the extension 10 legislation, which, of course, we had been also looking forward to ourselves daily, the first official act which was 12 taken and I happened to be the one in the chair at the 13 time was to institute the Council involvement by trying to 14 call this meeting together. 15 So, in fact, we view it as a very desirable 16 feature to have Council involvement in matters of 17 advising on policy and certainly in approving grant funds 18 for expenditure by RMPS. But the termination was vieve 19 as a necessary prudent managerial procedure and not requiring 20 Council. 21 That I think is the viewpoint. Whether legally 22 this position can be sustained I honestly don't know, and 23 we have been so busy trying to be prudent managers,with 24 both our internal staff and our external programs having 25 great difficulties, that we did not wait for a 4-month 48 1 written opinion from General Counsel, very frankly. 2 That is as honest a statement as I can make. And 3 as soon as our program has been extended, we have come back 4 -- not reluctantly but quite enthusiastically -- to seek 5 your advice as to how to advise us on matters of great 6 importance to us, and also, of course, at the appropriate 7 time, to approve the expenditure of funds. 8 DR. ROTH: Thank you. 9 MRS. MARS. Yes,, but now that these three are 10 actually phased out and there is a continuation, isntt it illegal that they're not to receive funds or are not being 12 dontinued? The three that are phased out -- the three @o p 13 programs? 14 DR. PAHL.@ Let me go off the record, please. 15 (Discussion off the record.) 16 DR. PAHL4. May we go on the record again? 17 Dr. Schreiner. 18 DR. SCHREINER@. Since one of our previous drives 19 was to get Ohio consolidated, I just wondered if it would 20 be appropriate to simply reassign the territory to an 21 existing, ongoing regional program. This really punts the 22 legal question, because you haven't phased out anything. 23 You9re simply redistricting. And maybe this is the right 24 time to think about it. 25 DR. PAHL@. I believe we will be considering 49 1 territorial questions at some point. 2 At this point it is fair to say, and for the record 3 it should be stated, that RMPS did, in fact, phase out the 4 three Regional Medical Programs, so at this point that 5 action has been taken. 6 I believe, Bob, perhaps you might care to comment, 7 if it was you who had that conversation, or-- Who had the 8 conversation concerning the activities from Northeast 9 Ohio in perhaps reforming-- Mrs. Kettle? Mrs. Kettle, would 10 you 6i@6 to make a statement, please? MRS. KETTLE4. As far as I know 12 DR. PA#LI. Would you care to use the microphone 13 so everyone can hear? 14 MRS. KETTLE-4 The acting coordinator who 15 stepped in to administer the phaseout procedures of Northeast 16 Ohio met with the chairman of the Regional Advisory Group 17 for Northeast Ohio, and they called a joint meeting of the 18 board of trustees. Northeast Ohio had a corporation as a 19 grantee. 20 And they met with the board of trustees last night 21 1 believe to see about courting Mr. Milliken, Mr. Cashman, 22 and called for assistance in tracking down some Ohio 23 Columbus -- people so that they could just discuss and 24 explore coalition. 25 DR. PAHL: Thank you. 50 1 1 would indicate that in terminating these three 2 regions the staff officially and the coordinators officially 3 indicated that both groups would be interested in providing 4 as much assistance to these regions as may be desired in 5 reforming, but at this point the Council does have 53 6 programs existing and not the 56. 7 Mr. Milliken, would you care to comment on any- 8 thing that you may know of? 9 MR. MILLIKEN@O This is all news to me. This is 10 the first time I have heard about it. 11 DR. PAHL' Well, we're all trying to get caught 12 up. 13 MR. MILLIKEN: I'm sorry. 14 DR. PAHLio Dr. Teschan, do you want to speak 15 for the coordinators in this? 16 DR. TESCHAN. No, everything has been said 17 exactly as we understand it. 18 MR. CRAMBLISS.I Imight call to memory of Council 19 that the Northwest Ohio Regional Medical Program did set 20 a precedent in Ohio. If you recall, that region at the time 21 was one of the, shall we say, weaker regions, and it was 22 merged into the Ohio RMP. 23 So we have had some history of this kind in 24 Ohio; and this Action that has been taken does not preclude 25 them from reapplying. 51 1 DR. PAHL@. All right. If we may move on, with 2 your indulgence -- I know blood sugar levels may be a little 3 low -- but if we can just get through a few more minutes I 4 believe it would be helpful to finish this part of the 5 presentations with Mr. Gardell at this point giving you 6 what our fiscal activities have been and then Mr. Chambliss 7 just winding up. Then we could break for coffee, delaying 8 the actions we were considering taking until a little bit 9 later. 10 At this point I would like to welcome Dr. Merrill 11 to the Council, who made a s cial effort to be here from Pe 12 out of town. Thank you, John, for making the effort. 13 And then we will again have to rearrange our 14 agenda in order to accommodate,Dr. Teschants presentation before he has to depart at 11@030. 16 So perhaps we will just take a few minutes longer 17 than we had originally proposed for the meeting, but I 18 think it will be better if we can continue the present report. 19 Jerry. 20 MR. GARDELL@. Thank you. 21 As you can tell, we have had some fun this year. 22 And I might thank my predecessors here in their 23 presentations because they have helped considerably to lay 24 the groundwork for the presentation I am going to make, 25 which is very brief, but to try to show you that we tried 52 I to stay within our legal limits, if you will call it 2 legal, as far as the amounts of money are concerned, both 3 from the standpoint of the Council levels, our funding 4 levels, and the amount of money available to us. 5 If you will excuse me, I will read from a 6 script prepared for me -- and I was the writer -- that hits 7 all the highlights. And I don't want to miss any of them. 8 So I hope you will understand what we had to do. 9 @We were prepared initially in 1973 to fund 56 10 regions on a 12-mouth basis, as usual, using a projection of at least $96.6 million. And, therefore, after the June 12 NAC meeting, we funded 17 grants for one year with a Septem- r@j 13 her 1 start date. 14 However, our allocation of approximately 15 $52 million for grants under the continuing resolution 16 caused us to announce on December 29, 1972 that we would 17 fund the additional 18 regions coming up with a January 1 18 date for six months only, in line with the NAC levels, 19 at annualized funding levels, but with the understanding 20 that the second half of the budget period would be made 21 at a later date when additional funds were made available 22 to us. 23 This was based on the assumption, of course, 24 that the appropriation act would be passed with an alloda- 25 tlon near our projection or maybe even better than that. 53 1 Finally, when the President's budget was sub- 2 mitted and did not include any funds for RMPS in 1974 and our 3 1974 allocation remained the samej we informed the 4 RMPs on February 1 that no grant awards would be made 5 beyond June 30, 1973 except that we would provide for phaseout 6 purposes but not to extend beyond 2/15/74. 7 The 17 September awards in accordance with this 8 decision were reduced by,tvd months, because they normally 9 would have ended August 31.1 And the May I awards which 10 should have be6h,made for 12 months were then extended or 11 just two months. 12 So an aside here is that what we are now 13 faced with is a possibility of one budget period involving 14 three separate fiscal years, so you can see we are going 15 to have some problems in reconciliation as well as just 16 plain making the funds available. 17 Budgets for all the programs were to be 18 negotiated in line with the criteria contained in the 19 February 1 telegram which Mrs. Silsbee mentioned to you. 20 Then the phaseout plans A and B were reviewed as 21 indicated by her and the programs were funded with 22 ending dates at that point ranging from June 30, 1973 23 through 2/14/74 depending upon a realistic assessment 24 of the staffing needs to complete the approved projects and 25 activities as reviewed and provided RMPs in our April 54 1 telegram. 2 A balance of approximately $6.9 million remained 3 from this process which could not be made available at that 4 time to the regions because of the phaseout decision. 5 Now, this is a combination of what our 6 normal operation is of offsetting against unexpended balances 7 that the regions report to us-, so that is how we came 8 up with the $6.9 million, which was in line with our 9 projection of our lapse anyway. 10 On June 27th, after the legislation was extended 11 on the 18th, the phaseout restrictions were lifted and 12 discretionary funding authority was reinstated to the 13 regions but with the understanding that they would hot receive 14 additional funds at that time. 15 On July Ilth, however, after the continuing 16 resolution was signed, authority was granted to us to 17 negotiate budgets with each RMP for funds from fiscal 1974 18 continuing resolution that would be necessary to maintain 19 the program's viability, providing for adequate staff 20 and activities at a level not to exceed three times the 21 avera e monthly expenditure rate for the period April 1 g 22 through June 30 to be made available for the succeeding 23 period July I through September 30, 1973 out of fiscal 1974 24 money. 25 It also permitted us to distribute the remaining 55 1 $6.9 million out of 1973 money but not to be used 2 until approved by us. And that was because the mission as 3 yet had not been defined and we wanted to make sure 4 that that money would be used hopefully In line with the 5 mission. 6 This distribution was accomplished by prorating on 7 a monthly basis the program staff costs for each region as 8 of 12/31/72,vhich we thought was a good operating point, 9 for a six-months period ending 12/31/73, but offset again y 10 the funds presently available to the regions for the 11 program needs for that same period. 12 This process resulted in, as was mentioned by 13 Dr. Pahl a balance of $2,449 of the funds 14 available to us for grants in fiscal year 1973. 15 We are presently reviewing the requested funding 16 needs of programs for the period 7/1 through 9/30/73, and 17 we will amend the current awards as the requests are 18 approved. 19 'Now, currently, the continuing RMPs have ending dates 20 as follows, and this is because we had to distribute the 21 $6.9 million and give them additional time to use it, but 22 that date is negotiable. 23 We have one program ending on November 30, and 24 that happens to be Florida. And the only reason is it 25 didn't get any additional of the $6.9 million, so, therefore, I 56 1 we will extend it through 12/31 so that everybody is at least 2 up to 12/31/73. 3 Nov, they have asked for An extension without 4 additional funds, so they have enough at least to remain 5 viable. 6 We have 21 ending on 12/31, four ending on I 1, 7 and 27 of then go through 2/14/74. 8 So these figures do change from the ones that 9 were mentioned previously, but that was prior to the time 10 that we have amended awards. Depending upon decisions regarding the coming 12 review process which we are going to be facing, it may be 13 necessary to extend further these programs that have a termination date of 12/31/73 to assure their continued 14 15 support until we can make them an award for 12 months or 16 whatever period of time is decided out of fiscal 1974 funds. 17 It may also be necessary to provide certain 18 programs additional funds beyond 9/30 to maintain their 19 viability provided for through the use of the first 20 quarter's allocation. In other words, some of them really 21 are taken through 9/30 with additional funds. 22 Nov, if that is not enough to take them through 23 12/31 until we can reach them with a 1/1 beginning date for 24 a new budget period, we will have to extend them again. 25 It should be clearly understood by all of you that 57 1 in these changes to the existing grants we have always 2 utilized the NAC levels of record annualized, and the 3 annualized funding levels, so we have not exceeded both. In 4 to instance have we exceeded the NAC levels and we do not 5 antlclp;tte that we will between now and the next review 6 cycle, and I think that is extremely important because it was 7 hard to do in our machinations to keep abreast of the 8 amount of funds available to us. 9 So that is the story of what we have done. I 10 have tried to do it in a nutshell for you. Now, if you have 11 any questions -- 12 DR. PAHL@. This is a very technical presentation, 13 and perhaps the major thing you have gotten out of it is 14 how complicated a set of procedures we have had to go through 15 in order to account for budget periods, ending dates, 16 fiscal 1972 funds, fiscal 1973 funds, fiscal 1074 funds, 17 continuing resolution, balance out of 1973, phaseout periods. 18 And one reason for having Mr. Gardell present it to 19 you was, first of all, you should have the information, 20 which I'm sure you couldntt absorb. Secondly, it should be 21 a matter of public record for one point in time what It was 22 that we did do. 23 And, thirdly, again I think it does indicate the 24 high level of professional activity which has gone on 25 internally in trying to accommodate both the congressional 58 1 intent and the Administration's position. And I believe 2 1 can speak for Dr. Teschan's group of 53 but formerly 56 3 coordinators who have repeatedly given public commendation 4 to Mr. Gardell and his grants management group throughout 5 this most difficult period. 6 So we are ready to entertain questions on any 7 matter, but it is a matter of record what we did try to 8 accomplish. 9 Mr. Milliken. 10 MR. MILLIKENie What were the two programs that 11 instatod? were re 12 DR. PAHL: The two programs that had been scheduled 13 for June 30th phaseout and were reinstated were North 14 Dakota and Puerto Rico, and there is a written record as to 15 why these actions were taken, and we will be glad at some 16 point to mention that to you. 17 But both were on the basis of very valid 18 reasons and merits of the case. 19 Are there any questions? 20 We will be talking a little bit more after coffee 21 about this $6.9 million balance in fiscal 1974 funds. 1 22 wouldn't be unduly concerned about all of the kind of 23 problems we have been involved with. It is very technical, 24 very complicated. But we at this point end up with all 25 regions being assured of funding for a sufficient period of 59 1 time that we can accommodate the legislative requirement 2 Of Council approvals, at the same time accommodating the 3 Department's position of still trying to determine what 4 the direction of the program should be, and this represents 5 a complicated set of actions going on simultaneously. 6 Dr. Roth. 7 DR. ROTH.@ I don't know whether this is a fair 8 question, but it would seem to me personally in trying to 9 adjust to the situation I would like some kind of a notion 1 0 about..,WhAt happens. You have got a one-year extension. Should one 12 be malting two gets of alternate plans, an orderly phaseout 13 presuming that there is no further extension or 14 revitalization of the program, or do you simply have to wait 15 for what is going on downtown in the Rogers Subcommittee, 16 for example, of considering ways of putting this together with 17 other programs for extensions? 18 DR. PAHL.@ Well, that is part of the heart of 19 what we should be talking about today, and with your 20 permission I would like to defer it and put it in a larger 21 context after we have had an opportunity to get you some 22 coffee and ourselves impart a little bit more Information to 23 you. 24 We need advice from you not just today but in 25 60 coming months about this matter4 But it is an importan 2 topic for today's conversation, so I would like to defer it 3 with your permission. 4 Jerky, thank you very much. And, of course, we 5 will be ready to answer any kinds of questions you may have 6 over the bourse of the day on this, but we did want to give 7 you a picture of the convolutions which we have had to go 8 through in order to maintain this period of activity in the 9 program. 10 And now, as the last brief presentation, Mr. 11 -Z, Chambliss does wish to end up not on a fiscal note 12 but to toll you what our overview is concerning the 13 programmatic activities of the regions today. 14 Bob. 15 MR. CHAMBLTSS: I would like to end on a program- 16 matic note. As we worked tovArds'th6 impbhdingphasedut of 17 RMPS, the Director sought to pull out certain specific 18 project activities for support beyond the June 30 1973 19 deadline, and these projects fell into three specific areas. 20 First, projects in the area of hypertension. 21 Second, those in the area of health services 22 educational activities. 23 And, last, those in the area of EMS, or 24 emergency medical service systems. 25 In the area of hypertension, RMPS had under 61 support about eight projects totaling approximately 2 $1 million, and these were selected out for continued support 3 as far as they could go depending on the determined phaseout 4 date of an individual Regional Medical Program. 5 Also in the area of health education activities, 6 as you recall this is the area, health education type 11 7 activity, supported by Regional Medical Programs that took 8 off on the initiative as set forth in the Carnegie Report. 9 As Mrs. Silsbee pointed out in her expression to you, we 10 are supporting about 11 percent of all the projects that 11 were identified for continuation in the area of health 12 education activities. 13 And in this health education activity area 14 the staff has endeavored to visit all of these projects 15 that had high potential for viability. 16 If you recall, about $6.8 million was awarded to 17 the regions for this type of activities, and these activities 18 vent on in 27 Regional Medical Programs. About 38 of these 19 projects vent for developmental or operational activities, 20 and about 41 of these projects were for the support of 21 feasibility studies or planning studies. 22 Now, as we began to contemplate the phaseout, we 2,3 felt that there was a need to site visit each of the 24 identified projects to assess their progress, to update our 25 knowledge on them, to see what t e of evaluation was being yp 62 1 conducted, and to determine if possible their potentialities 2 for continued support perhaps from some other source of 3 support in HEW. 4 Now, to date, out of 15 RMPs that were identified 5 where site visits should be made, we have conducted 11 of 6 those site visits by members of the staff, and there are 7 four of those site visits to RMPs yet remaining to be con- 8 ducted. 9 We have set up a task force of Regional Medical 10 Program staff, and this has been augmented by representatives 11 from the Bureau of Health Manpower. They have been 12 augmented also by representatives from the 13 Veterans Administration and also from the regional offices, 14 and representation has also come from the Secretaryts office, 15 to see how these projects were moving along. 16 'We think that this perhaps has been one of the 17 most worthwhile areas of support that RUP has engaged in. 18 These independent, community-based consortias have proven 19 to have started a new type of activity at the local level 20 bringing together educators, providers, health institutions, 21 and consumers, all sitting around the table to discuss 22 health manpower needs at the local level. 23 As one of the site visitors has reported, one 24 person at one of the RMPs indicated that this is the type 25 of activity that should have been engaged in at the local 63 1 level 30 years ago, to bring this coalition of people to- 2 gether to discuss manpower needs of a specific location. 3 Then in the area of emergency medical services, 4 funds were awarded to the RMPs out of 1972 supplemental 5 funds in the amount of $8.6 million. These funds went to 6 28 separate RMPs for the support of 34 emergency medical 7 services planning and operational projects. 8 Now, these projects ranged in dollar amounts from 9 $16,000 up through.over $1 million, the highest being $1.7 10 million. However, the majority of these projects ranged in amount from $25,000 through $100,000, and there were 12 three that exceeded the $1 million level, Wisconsin, Tri- 13 state, and Havaii. 14 Here again a task force was established of RMPS 15 staff members. This staff has been augmented by staff from thLb 16 National Center for @lth Services Research and Develop- 17 ment headed by Dr. van Hoek, and there has been Joint 18 planning effort toinvolve their staff in going to some of the 19 larger and more critical EMS activity projects, and they 20 have done so. 21 Out of a total of 28 RMPS, 20 site visits have been 22 made. There are only three remaining to be done at the 23 moment. And the objective of these visits has been to again 24 update bur knowledge, to assess the project being made to 25 determine whether the plan for a given project was being 64 1 tion, to assess carried out in accordance with the applica 2 th d emergency medical activities e development going on ardun 3 sponsored by RMPS, and to see if there were involved in the 4 evaluation component where ongoing program activity an 5 some assessment could be made as to the productivity, the 6 viability and the strength of a given M project. 7 Of course, these projects touched on communica- 8 tions, planning, transportation, public education, training, 9 equipment, and the development of local EMS councils. 10 We feel around this activity there has been a 11 significant developmental activity to improve emergency medi- 12 tal services and to develop a high sense of awareness of 13 the need for concerted planning and systems development for 14 the care of the emergency patient at the local level. 15 I might say one thing that came to my attention 16 about a visit I think you would like to know. Tn the 17 Alabama Regional Medical Program an award of about $150,000 18 was made. There was to be training for a total of 1,200 19 people, trainees, in the program. With that amount of money 20 they have trained in excess of 1,400 people.,' 21 At one of the hospitals where a training program 22 had been conducted and completed during the hurricane 23 season, ten days after the training project was completed 24 that community was hit with a tornado. There were 47 victims 25 brought to the hospital wherein the training program had 65 1 been conducted just ten days prior thereto, many with 2 very serious traumatic injuries. The staff was 3 alert and ready to perform under stress, catastrophic 4 circumstances. The patients were treated. Triages were 5 set up. The emergency medical plan, involving the health 6 department, the police department, the fire department, and 7 all other emergency activities, was brought into play, and, 8 as was pointed out, it was a great demonstration of the worth- 9 whileness of this type of activity. 10 Here again we thought you would like to know that just as a matter of information. 12 if I may summarize then by shifting over to 13 another set of activities that is ongoing in the RMPS, 14 we thought you would like to know that of the 53 RMPS, all 15 have coordinators. However, there are ten acting coordi- 16 nators on duty now. Three of those coordinators you 17 already know were acting, but the new acting coordinators 18 are Mr. Edward Morrissey in Connecticut, Dr. Francisco in 19 Northern New England, Dr."Harrison Owens in Nassau-Suffolk, 20 Dr. Stephen Langfeld in Greater Delaware Valley, Mr. Chad 21 Combs in Susquehanna Valley, J. L. Robertson in Alabama, 22 and Mr. T, R. Newman in Ohio Valley. 23 This gives you some indication of the viability 24 of the R@ , that they are still engaged in holding on to 25 their leadership and recruiting leadership for the support 66 1 and continuation of the RMPS. 2 Time is short, and let me say if there are 3 any questions I will be glad to answer them for you. 4 DR. PAHL.@ Thank you, Bob. And I apologize, 5 because I think it was my exuberance this morning which 6 perhaps shortened your time. And since I have been in the 7 same position, I apologize and appreciate your summarizing. 8 1 think we have had quite a bit of material, and 9 with your indulgence T think it would be perhaps well if 10 we broke here for coffee. Dr. Teschan has repeatedly Indicated to me he 12 has to leave at lli$30. I think it is very important that 13 you have his presentation before he departs because he does 14 represent the other coordinators and itts important you 15 hear from them through him. 16 So if we could break for coffee now and reconvene 17 at no later than ten after-- And please bring your 18 coffee back with you, but get a stretch, and then we will 19 have time I think-- Paul, will that be sufficient? 20 - DR. TESCHAN: 11:05 would be better. 21 DR. PAHL'. Make it 11.0-05, if you can, please. 22 (whereupon, a recess was taken.) 23 DR. PAHL@. May we sit down at the table, please, 24 and come to order? 25 Without taking further time from Dr. Teschan's 67 I presentation, I would like to say that we are very pleased 2 to have him here because what we have been presenting to you 3 so far, of course, is the RMPST view of what has happened, 4 why it has happened, and where we now stand, and it Is most 5 important that you have directly, firsthand, the view from 6 not only a coordinator of one of the programs but 7 the spokesman for all of the coordinators of the RMPS. 8 Paul. 9 M. T.ESCHAN@O Thank you, Dr. Pahl. 10 First of all, I think itts important that you understand that we of the coordinators and the members of the 12 regional Advisory groups are enormously appreciative of Herb 13 Pahl and Jerry Gardell and the staff's activities in 14 support of the RMP. The facts are 53 of the 56 programs 15 have come through this very difficult time. 16 1 feel that the degree of discouragement, 17 the erosion of morale and the damage which has been done in 18 the regions would have been far greater if we hadn't had 19 the kind of steadfast support and the kind of very 20 careful attention to our individual problems which this staff 21 has continued to give in spite of all their problems In 22 dealing with the shifting administrative pressures that 23 you have had just a little glimpse of here. 24 So ltd like to say I fully agree with the 25 comments that have been made today, and we are fully in 68 1 accord with the idea that what procedures the staff has 2 undertaken, with the possible exception of convening this 3 Council once more in the area of March and the awards 4 with that possible exception -- we are fully appreciative 5 that, given their situation and their direction, they have 6 proceeded as best they could, and we appreciate it. 7 Novo I think the important message, quickly, that 8 1 would like to-- There are several important messages I 9 would like to communicate to you, and I much appreicate 10 this opportunity to do so. 11 The first point, and the overriding point I 12 think, is that RMPs are still under attack within the 13 Administration, in our view. The coordinators consensus 14 is that the evidence is clear that the phaseout has not, in 15 effect, been rescinded, that the practical operating 16 circumstances of the programs are not compatible with what 17 has been called here revitalization. It's not the case. 18 And, therefore, I want you to understand the 19 way it looks in the area where we operate. For example, 20 what has come by a rescinding of phaseout restrictions is that 21 within the phaseout order we now cab rebudget between 22 continuing projects and staff. Well; that still spells 23 phaseout. 24 And in view of the one-quatter authdrizat ons 25 it follows that recruitse0t which you have also heard about, 69 1 is out of the question. 2 Commitments of any substantive or significant 3 scope are also out of the question. 4 1 have also determined this morning that 5 the reduction in force program imposed upon RMPS is still in 6 effect. 7 We understand through our various communications 8 that the Secretary still maintains precisely the attitude 9 that he had when we last met together on February 7th. 10 Nov. the particular point I think we should get 11 into more specific detail on has to do with the telegram 12 from this,office on July 5. In that telegram there was 13 a notification that negotiations would be underway for 14 a level of support to assure viability through the first 15 quarter. Well, eve yone knows through five years or more 16 of experience with this program that the RMPs do not 17 operate on a quarterly basis, that the intent of the law is a 18 one-year extension. The intent of the authorization and 19 appropriations is a one-year extension. 20 Therefore, a quarterly allocation and authoriza- 21 tion are in contravention of the Intent of the law, and this 22 is the way the coordinators see it. 23 Now, you understand, and I want to reiterate 24 here, I am stating a viewpoint from the way we see it. This 25 is in no way to be interpreted as a criticism of Dr. Pahl I 70 1 or the situation in which the RMPS staff must operate. 2 1 am not holding them responsible for what I am seeing, 3 but I am leading into what I propose and offer to you 4 for your consideration as to action or position which this 5 Council might wish to take. 6 The second element of the telegram of July 5th is 7 that the RWS has been authorized to utilize $6.9 million of 8 unexpended PY 1973 funds but that no expenditure may be 9 made until the Department announces the mission of the 10 Regional Medical Programs Service for the rest of 1974. 11 Again let's recognize that the Congress extended 12 RMP. It did not write a new law. It did not create a 13 new situation At all. This Council has approved an 14 authorized mission statement under which all RMPs are 15 operated. There is at this point no Countil-apprdved or 16 Council-authorized change in the mission. 17 Classically, the RMP has generated the mission 18 statement from this Council and not from higher up in the 19 Department. 20 So our view is that we have a mission and that 21 there is no basis for a further mission statement at this 22 time under the intent of an extension of the law. And 23 certainly, therefore, the idea that then the $6.9 million 24 may not be expended until there is this new mission statement 25 is an additional obstacle, obstruction. That is, in effect, 71 1 the money does not flow in spite of the intent or the 2 language saying that we now can obligate it from RMPS. In 3 fact, the money does not flow. It has another contingency 4 which we see to be virtually illegal in view of the extension 5 concept which the Congress intended. 6 There is another element in this July 5 telegram 7 that says that proposed RMP activities, presumably reviewed 8 at intervals, will need to meet review criteria to be 9 established -- another sense of obstruction and delay and 10 e interference with the purpose of th Congress to extend the 11 programs. 12 And the RMP coordinators are somewhat exercised 13 as you might understand on those points. 14 DR. PAHL.@ Paul, if I may just interrupt for a 15 moment, we have included these telegrams in your folder. 1 16 dontt think you have to turn to them right now, but we cab 17 consider them after Dr. Teschan has to depart. 18 It's the last set of yellow sheets under the ta) 19 called "Phaseout," which is the third tab from the back. And 20 the last yellow sheet is that July 5 telegram Dr. Teschan 21 has been referring to. We can take that up at greater 22 length following his presentation. 23 DR. TESCHAN: The point of this discussion is 24 really not the detail of the telegram@as:sudh but the 25 significance of it aslits effect is, felt in the regions 72 1 where the action is supposed to take place. 2 1 think the overall issue that I am indicating is 3 that the intent of the Department is to continue the phaseout 4 of RMP, to place obstacles in its way and essentially to 5 proceed despite the fact that the congressional support as you 6 have ju0t seen and the Presiddntts signature exist. 7 Now, our feeling here is that the Council needs 8 to take a stand, and a stand has been prepared as an offering 9 for your consideration. Dr. Roth has already referred to it. 10 And it reads like this in the draft that we would offer for 11 your considerations. 12 "The National Advisory Council on Regional 13 Medical Programs believes the February issuance of phaseout 14 orders with subsequent amended awards to each individual 15 RMP was in violation of Public Law 91-515 because those 16 orders and awards were never approved by this Council. 17 Therefore, the Council hereby recommends to RMPS that all 18 previously issued phaseout orders be rescinded immediately." 19 We would also offer for your consideration the 20 possibility of your recommending that the awards 21 actually made under what has been called phaseout be retro- 22 spectively legalized that is, approved by the Council. 23 Nov, all we mean in connection with Dr. Rothts 24 previous question on this point is that the language in 25 section 964(a) simply indicates that awards are made as 73 1 standard procedure by the Secretary on recommendation of 2 this Council. The so-called phaseout awards and these inter- 3 vening awards now have not been so processed. But I 4 think the Council could undertake that at this point. 5 "Public Law 93-45 continues RMP for one year, or 6 until June 30, 1974. The lawts substantive language remains 7 the same. This Council has approved the mission statement 8 for RMP that is consistent with the provisio s of the presen 9 law. The Council regards this mission statement as still 10 valid and any subsequent mission statement at this time 11 is unnecessary and inappropriate.' Likewise, previously 12 adopted policies of this Council shall remain in effect 13 until altered or revoked by this Council. 14 '4The Council hereby authorizes RMPS to issue 15 d awards up to the existing 1973 approved level of amende 16 each Regional Medical Program, and that these amended 17 awards be made to all RMPs for the entire 1974 fiscal 18 year as soon as money becomes available. Future awards to 19 the regions should not be made for less than one year al- 20 though supplemental awards for the remaining months in this 21 fiscal year may be made after appropriate consideration 22 by this Council. All interim awards which have heretofore 23 been made for maintenance of program staffs are hereby 24 approved." 25 And that is the issue I indicated. 74 "Finally, the Council reconfirms its faith 2 and confidence in the concept of RMP and urges the Department 3 to reconsider its position relative to RMP." 4 And Ttll leave this copy with Herb if he finds it 5 useful. 6 I think the issue could be summarized further 7 this way. The RMPs today are the remaining long-shot 8 chance of a cooperative enterprise between the 'Federal Govern- 9 ment and private providers and private enterprise in the 10 health care field. There is really no other way by which 11 the panoply of the bureaus and agencies which you saw in 12 the organization statement and charts can see their effect 13 actually occurring in the towns and cities and neighbor- 14 hoods and crossroads unless there is an in-place mechanism. 15 There is no other competitor for an in-place mechanism to 16 get it to happen. 17 Assuming for a moment, therefore, that if it is 18 intended that there will be effects in EMS, that there be i9 effects in inequality assurance area, etc., these effects 20 will occur because they happen in localities, not because 21 they happen only at the bureau level. 22 We see also, as Mr. Van Nostrand has 23 clearly pointed out to us today, an erosion of RMP's 24 mission by the Administration assigning to new bureaus and 25 new agencies the kinds of activities which have been RMP 75 1 prerogatives and responsibilities up to now. However, that 2 is a fraudulent position, because you won't get it to happen 3 by the establishment of a new bureau on an organization 4 chart or filling additional offices with additional 5 personnel in Parklawn Building. I'm sorry. 6 Therefore, our presentation to the Assistant 7 Secretaryts office has been that RMP be recognized as the 8 local in-place organization for the implementation of the 9 whole variety of Federal health initiatives which need 10 local application. We in the RMPs could very easily see 11 these bureaus that you have just seen as the resources on 12 which we call to implement these things. 13 You will see I think shortly some further comment 14 that the regional offices, the ten of them of HEW, are 15 supposed to have this type of activity and role. Our 16 feeling is that in our area, for instance, in Tennessee, 17 that the regional office in Atlanta is as remote to the 18 hills And valleys that we ate familiar with and work in 19 as would be a bureau in Washington. 20 So I think the critical issue here is that we stil 21 have a fighting chance, an uphill fighting chance, to 22 establish and to develo public and private partnership p 23 in the' effect -- that is in getting the activities to 24 happen In the communities of the,tegion if RMP is so 25 recognized by the Department, the Administration, and by this 76 1 Council. 2 We believe that there are, secondly, four areas 3 of mission which the RMPs are able to do: 4 First of all, we do believe we have a role in 5 quality assurance and would cooperate with the bureau with 6 that name in implementation activities. 7 Secondly, we believe that we have a track record 8 in the proved utilization of manpower and a track record 9 in developing the colmunity-based area health education 10 consortia. We are able to do that and should be mandated 11 to continue it. 12 Thirdly, we have obviously demonstrated 13 capability, as Mr. Chambliss has indicated, in improving 14 primary care services, including EM. We should be 15 mandated to do that from the EMS office. 16 We have five years' established experience in 17 regionalizing specialized services and the HEW should be 18 using RMP for that purpose in their communities rather 19 than in each of these instances eroding the RMP's energies 20 and contribution by separate bureaucratic mechanisms 21 for these localized fragmentary initiatives in the health 22 care field. 23 Now I would like to go off the record for just 24 a moment. 25 (Discussion off the record.) 77 I DR. PAHL@O Thank you, Paul. I know you are 2 dashing for an airplane. Is there any point that-- Dr. 3 Merrill? 4 DR. MERRILL@. I'd like to ask Paul a question. 5 Is it your opinion that the vehicle through which an 6 expression of opinion by this Council should be made is a 7 resolution written out and transmitted to the Secretary? 8 DR. TESCHAN: I do believe so. 9 M. MERRILL" I'm not convinced that action would 10 be greatly effective. 11 ]OR. TTSCHAN@* Youlrd asking that at two levels, 12 John. My answer to that is, yes, a resolution that is 13 resolute and clearout and unequivocal may have no immediate, 14 direct effect In moving affairs, but it doesn't detract 15 from its value, because the National Advisory Council 16 will be on record. It will raise a standard around which 17 others can rally. And essentially this is a very important 18 area if private and voluntary participation is to enter the 19 health field and continue in the health field. 20 So don't underrate the significance of your 21 action. 22 M. PAHL. Thank you very much, Paul. 23 1 am afraid that because of the need to return 24 to the Southern Coordinators' meeting Paul will not be able 25 to be with us this afternoon during the discussion. We have 78 I assured him that we will get to him what does transpire. 2 Before we move on, I would like to say as the 3 acting director of the program that we do endorse the 4 statement that Dr. Teschan Just made. That is, we do believe 5 that th is Council should play a very real role in the 6 policies and activities of the program. And the reason we are 7 meeting today in July is to tot only bring you up to date but 8 to look to you for that kind of advice and formal advice to 9 the Department, the Secretary, the Assistant Secretary for 10 Health, the Administrator of Health Resources Administration, 11 and myself as to your interests and concerns. 12 And so I would like to fully support Dr. Teschan 13 in this plea for very strong Council involvement regardless 14 of what position that may be on your part. 15 Nov. with that, I would like to say one more 16 thing and then perhaps open it for discussion. 17 One of the things we were not able to do this 18 morning was to distribute prior to the coffee break our 1.9 one proposed Council resolution which at least includes 20 one part of that which Dr. Teschan distributed. And, Yen, 21 if you will distribute that. 22 1 am not asking for action on this at the moment, 23 but I think you will be considering the proposal that Dr. 24 Teschan made, and you will see in the proposed resolution 25 that we have drafted for you, if you will, the need to 79 1 endorse actions which we have taken particularly as regards 2 the adjustment of budget period and the proration of funding 3 levels and Council ceiling support levels of regions that 4 Mr. Gardell was telling you about, technical aspects which 5 we had to engage in in order to keep the programs Alive 6 and which we may still have to engage in during the coming 7 months. 8 So I'd like to have you read that and consider I that @ther with Dr. Teschants more inclusive proposal. 10 DR. McPHEDRAN.i Dr. Pahl, -- 11 DR. PAHL: Dr. McPhedran. 12 DR. McPMO)RAN@. -- I wanted to ask a question 13 about this telegram, that is, the telegram that Dr. Teschan 14 read, which is the last yellow thing in the phaseout section 15 of the agenda, particularly about this matter of stipula- 16 tions that no expenditure be made therefrom until the 17 Department announces the mission of the Regional Medical 18 Programs Service for the remainder of fiscal year 1974 and 19 that proposed RMP activities meet review criteria to be 20 established. 21 @'You must have had some reason for putting that in. 22 1 must say I would 'agree with Dr. Teschants interpretation 23 of that, and I wondered why this was put into the te egram. 24 Why were those stipulations made? 25 DR. PAHL@O These stipulations, although the so I wording is ours, were put in the telegram on the basis of 2 requirements which came out of the Department. 3 Nov, let me amplify that a little bit. I think 4 1 would like to go off the record for a moment, please. 5 (Discussion off the record.) 6 DR. PAHL.@ Before continuing the discussion, 7 because I am not quite certain what Dr. Laurts schedu e 8 might be, having just come from downtown and as Acting 9 Administrator of Health Resources Administration undoubtedly 10 having to leave shortly to do other things, and being 11 fully aware and involved in all of the activities I have 12 just indicated to you plus others which I have hot been 13 privy to, 1 think if you will permit we might hold Council 14 discussion and take advantage of the fact that he can be 15 with us and ask him to either address any question that he 16 may care to or respond to some questions from you. 17 And in this connection I would like to welcome 18 you, Bob, to our Council and ask you to take as much time 19 as you might have to reflect on matters either of 20 organizational or RMPS variety, the latter being, of course, 21 the preference. 22 DR. LAUR@. Thank you, Dr. Pahl. 23 These Are times where rim not so sure it pays to 24 "stop and reflect. 25 1 would like to do a couple of things if I may. 81 1 First of all, express greetings to you from Dr. 2 Edwards. He and I were just now at a meeting with Secretary 3 Weinberger on some other matters, and Dr. Edwards had hoped 4 to be able to come out here and visit with you during this 5 meeting. He still has that hope but I think it is diminish- 6 ing as the day goes along and other events intrude on his 7 calendar. 8 But he did want me to convey his greetings to 9 you. 10 Secondly, of course, to convey my own. This 11 Council has not only served our predecessor organization, 12 HSMHA, exceptionally well over the years, but your willing- 13 ness to come in now under short notice and with so many 14 uncertainties I find very gratifying, and we are most 15 appreciative of your willingness to help. 16 1 guess I'd like to keep the remarks short 17 for two reasons. One is this spot on these agendas always 18 provides an interesting time for the staff, especially 19 now where there is a new person, not new to the organization 20 but new to the day-to-day workings of RMP. I'm sure the 21 staff always wonders, "What will that damn fool say next and 22 get us in trouble over." 23 So, you know, itts an interesting little tense 24 time for them when these sessions occur. 25 And from the point of view of the Council it I 82 1 rough another 20 minutes of inanities means sitting tb 2 from an Administration official who isntt very much 3 involved in 'the process and it's a little difficult to endure. 4 So I thought for both of those reasons r 5 wouldntt say much. (Laughter) 6 But r would like to respond as best r can to any 7 questions you might have or observations you have about 8 this rather difficult situation we all find ourselves in. 9 And I would only make one observation that may or 10 may not help you understand the kind of direction that 11 we will be trying to provide RMP in the new Health ReOources 12 Administration. 13 rt seems to me that the first question was 14 the question that motivated this Council originally, 15 that motivates theIpeople who work in Regional Medical Progrant 16 around the country, and that motivates the staff, and 17 0 that is. What will be best for patients in the country? 18 What can be done to make the greatest contribution to the 19 improvement of health of people? 20 And if we start with that concern, other consideta- 21 tions I think begin to fall into perspective as to whether an 22 organizational arrangement is or is not very critical to 23 improving the care of patients or the health of people. 24 Well, I only offer that as an observation which 25 1 think motivates the staff, which I know has motivated th s 83 1 Council, and its predecessor members. And I would always 2 like to keep that as one of our fundamental concerns as we 3 plov ahead. 4 Even with that noble motivation, we will have 5 difficulty doing the right thing. Therd is no question but 6 what in the weeks and months ahead we are going to make 7 some mistakes in the Health Resources Administration as 8 we try to administer these programs. I will probably 9 make more than anybody else, first because I probably am 10 better at it, and also because of my naivete in some of these 11 areas. 12 It seems to me that the only contribution 13 might be able to make is that we would like to have our 14 mistakes called to our attention as rapidly as you discover 15 we are making them, and on that basis urge you to 16 be in touch with myself and with Dr. Pahl and the staff of RMP. 17 I simply do not believe in advisory councils who 18 don't contribute. This Council has certainly not had that 19 reputation. It has been an outstanding one. And even in 20 the situation we are nIov in I vouldllike very much to have it 21 be a functioning Council that you believe is important 22 and you believe is making a contribution to HEW's efforts. 23 So I want to say as we struggle through the next 24 period please lot me know if you think that will make any 25 difference, if that will be helpful to something, how we 84 1 could do things better, and remain in touch with Dr. Pahl 2 and the staff. 3 Well, enough of a preamble. If anyone has ques- 4 tions or observations ltd welcome them. 5 MRS. MARSO@ Do you see any real future for RMP 6 beyond this year? 7 DR. LAUR@. Okay. That is certainly a very good 8 questions, Mrs. Mars. 9 ring Dr. Roth DR. PAHL@ I held off ansve 10 until you came because I wanted also to hear the answer. 11 DR. LAUR@* You were all waiting to hear the 12 answer. (Laughter) 13 MRS. MARS4. Right. You realize this is a very 14 frustrating experience for everyone concerned, particularly 15 the Council members,. 16 DR. LAURI. I'd like first of all to ask if 17 someone would kind of keep track of me and not let 18 me respond too long. I could go on at some length on that 19 question. 20 ltd say two things. There is absolutely a future 21 for the kind of fundamental activities that RMP has been 22 addressing its6lf Ito across the country. By that I mean the 23 Involvement at the local operating level of the key 24 participants in the provision of care in a way that causes 25 them to make things happen that would not otherwise happen 85 1 or would not happen as rapidly. 2 Now, that is a long, sort of abstract statement, 3 but I believe at the local level or regional level, if you 4 vill,,in assembling resources to improve the delivery of 5 care to patients, Regional Medical Programs have een an 6 effective instrument at least in some instances and that 7 there is no substitute for the kind of involvement that 8 those effective instances have demonstrated. 9 Now, whether it continues as Regional Medical 10 Programs in capital letters federally funded by HEW, and so on, that I think is yet t6 be answered. There is 12 @uite a ways t gone as to what the Department's position 13 is going to be, what the Congrdss' position is going to e, 14 what your recommendations to us will be. All of that lies 15 before us. 16 1 simply cannot myself envision a world, given 17 the kind of health care problems we have and the limited 18 resources with which we have to work, where we would ignore 19 the kind of activity to which the RMPs have been addressing 20 themselves. That would astound me if that were the case. 21 I will hazard on the record a personal observa- 22 tion about the specifics of RMP in the sense that it is the 23 challenge to the Health Resources Administration, the 24 staff and the Council right now in the next several short 25 months to come up with a proposal to the Administration I 86 1 which will be accepted which will foster the kind of activity 2 1 have already alluded to. 3 Now, I haven't sensed personally -- and my 4 involvement in RMP is fairly recent, fairly superficial 5 but I havenft sensed an outright opposition on the part of the 6 Administration to the concept of Regional Medical Programs. 7 The concern has been one over has the concept (a) been mal- 8 addressed, you know. Have we si!%ply gone at-a good dea 9 in an ineffectivtz- vmLv? a have we devoted more 10 resources to the concept than the concept merits? You know, int in time? at least at 12 It has been those kind of concerns that I think 13 were addressed. And I would have to say also that 14 those concerns were raised at a time in which it was 15 absolutely necessary to make very substantial cutbacks in 16 the Federal budget. 17 In other words, questions that otherwise might 18 have been not so deeply and poignantly actures@vere 19 addressed under those budget-cutting circumstances. 20 Whether those circumstances are still with 21 us or not I think other people have to determine besides 22 myself. They certainly haven't totally gone away. And 23 that will condition how much we can aspire to with RMP. 24 But I believe the Health Resources Administra- 25 tion-- I e@ct-- I wouldn't even be interested in working 87 1 in HRA riaht now if I didn't think we were going to come up 2 tuation of RMP-type activities. with some 3 MRS. MARS4. But not as RMP as such? 4 M. LAUR@. I don't know about RMP as such. I think! i 5 that has to be thought through. 6 Given-- How can I put this and not sound unkind'? 7 1 was about to say given the barnacles which RMP has 8 accumulated and that's not a very kind way to put it 9 but there are a lot of associations with RMP right ww, and 10 some of those may be impediments to doing what we can to 11 improve the health care of people, you know. 12 RMP in my estimation-- I had a very satisfactory 1 13 relationship with it. It doesn't have barnacles from my 14 point of view. Itts something that I mou@,ldntt mind 15 continuing AO, y U"knowl capital letters, Regional Medical 16 Programs. But I think we have to weigh that as to whether 17 those words are the right words. 18 The first question is@. What is the activity, what1 19 is the function that can'be addressed, and what is the 20 Federal role in that function? 21 Then if it ought to be called RMP, we'll call it 22 RMP think. 23 DR. PAHL@* Dr. Merrill? 24 DR. MERRILLI. No. 25 i M. McPHEDRAN. I have some things to say About 88 I that. 2 You know, the Council wasn't mute on February 7th. 3 At least I wasntt. I had something to say at the time. 4 This Is in response to something that Dr. Teschan said in 5 his remarks. 6 1think that I thought at the time that it was 7 too bad to see the whole thing apparently being discontinued 8 at that time, and I said at the time I can't remember 9 exactly how it was said that it was done out of ignorance 10 more than out of wisdom. And I still feel that that's SO. 11 And I think the ignorance, for example, is 12 reflected in this statement in the telegram that I referred 13 to that no expenditure be made until the Department 14 announces the mission for example when this was done 15 as part of continuing resolution. There was a mission and i 16 there were review criteria that had been established, and 17 this could have been put in the telegram. 18 Obviously, Dr. Pahl put it in because someone 19 else told him that he should. But it couldntt have been put 20 in by anybody who knew how the thing had been operating. 2 1 So that I think that it seems to me that the 22 actions that were taken were takdn,in blissful or perhaps 23 not so blissful ignorance and not in wisdom. 24 It doesn't seem to me to@have been a sensibly 25 planned kind of activity. 89 1 1 really find myself, as I have reflected on the 2 suggested statement prepared by the coordinators, pretty 3 much in support of what the coordinators.have felt about 4 this. 5 I think that it's surprising in the site visits I 6 have made to find the number of Regi,@onal Medical Programs thati 7 did as good ajob as they did. I thought it was 8 surprising to find as good staff work from RMP as there was. 9 This is a new kind of activity for me. I never 0 knew anything about it before 1970, so r learned everything about it right here and on the site visits. 12 And I know that the barnacles are there, but it 13 seems to me that what is implicit in your suggestion, @,j 14 Dr. Laur, that there might be some other vehicle to carry 15 on this mission is that the RMPs in the various regions 16 would probably be disassembled. And some of them are really 17 very good. They are not all, but some of them are really 18 very good. 19 And it would be just a shame and a pity to do that, 20 I think, just as it would be a shame and a pity to take away 21 their e activiti s in quality assurance and manpower need 22 assessment and their activities in improvement of primary 23 care and EMS. 24 1 agree with Dr. Tes6han that the more of those 25 things that are taken away, the less effective will be the 90 I Regional Medical Programs. 2 1 think that it would be far better to go back, 3 if we could go back, to where we were eight or ten months 4 ago and try to scrape some of the barnacles off, as probably 5 will be possible with some of the phaseouts that have been 6 done. It may be easier to get some of the barnacles off 7 and go on with the organizations that were good and pursue 8 the policies of this office before, which were in the main 9 selection for funding of programs that were good and were 10 satisfactory, if there were hard times not to make across- 11 the-board cuts. This is a policy of the previous Director 12 which I concurred with and I think everybody on the Council 13 did as well. 14 1 think it would be really a shame to take apart 15 these various regional organizations-, Some of them me could 16 do without, but many of them ate really very good. 17 And I cannot help but believe that the direction 18 for the phaseout, as I said before, was done by people who 19 really did not know what they were talking about. 20 DR. LATJR@. I don't know how to respond to tha 21 If I say I totally agree, I have got a problem on one 22 hand. It seems to me we are saying the same thing, which 23 is there is a useful activity there. If it ought to remain 24 as Regional Medical Program, then let's try and do that. 25 If it ought to be strengthened or if there ought to be some 91 I changes made in certain aspectsp letts decide as best me 2 can what those changes are and see if we can get them 3 accepted. 4 But this group probably more than-- I'm sorry. 5 Does this microphone bother somebodyls eardrums? If we've 6 got cardiologists or somebody in the room who are so care- 7 fully attuned to listening to little thumps and noises, this 8 probably drives-&em crazy. 9 This Council perhaps mote than any group we 10 could assemble does understand, I think, the very real 11 world we now face as we move ahead with the kind of program 12 you have described, Dr. McPhedran, and thatts that some 13 very important and very well intentioned Administration 14 officials have decided, under the circumstances decisions 15 were made in, about what the future of RMP should be. If 16 we are to ask them to change their minds, I think we are 17 going to have to apptoachn it in a way which they 18 will find persuasive. And, you know, I think that's the Jo 19 we have in front of us. 20 - I don't@ think they are about to be steamrollered. 21 1don't think they're about to suddenly decide 22 that the anal sia they vent through, on whatever basis, is y 23 suddenly wrong and they wish they hadn't done it and so they 24 are going to do everything differently. I don't believe that 25 is going to happen. I I 92 I do believe that we have not found a way moo 2 personal opinion -- to express what it is that Regional 3 Medical Programs do in a *ay that ot Intimately 4 involved in the activity can understand. 5 Time after time after@timeo even among knowledge- 6 able health professionals, I have found it necessary to 7 take a half an hour to articulate what it seems to me 8 was the real function of an RMP as opposed to the kind of 9 transitory projects with which an RMP might be engaged at 10 that moment. 11 And if you have to do that with knowledgeable 12 physicians and hospital administrators and health officials, 13 then it isnft surprising to me that economists or budget 14 officials in the Federal Government or Congr6ssmen might have 15 some difficulty with the whole concept. 16 So we have a challenge I think as a staff to 17 find ways to articulate that, and that's in part, Mrs. Mars, 18 what I meant earlier about maybe a new word will be required, 19 MRS. MARS: Yes. 20 DR. LAUR.@ just to express the same activity. 21 DR. PAHL@6 Dr. Merrill. 22 DR. MERRILL$. This bears a little bit on the 23 question I asked Dr. Teschan, because, although I dontt have 24 it in front of me, it seemed to me his statement was really 25 kind of affirmation of the status quo. I'm not sure how 93 I effective that is in the present climate of opinion. 2 rceful and effective And I wonder if perhaps a more fo 3 instrument emanating from this body might not be a 4 revision perhaps embodying things such as no across-the-board 5 cuts, but paring specific barnacles, i you will, and some 6 positive suggestions to which the Administration might be more 7 receptive than simply strong affirmation of the status quo. 8 9 DR. ROTHO@ I'd like to ask a couple of I think 10 related things. 11 We referred to this, telegrato@with the implication 12 at any rate that there shall be a new mission statement. Do 13 we have anything po6king on the stove in terms of staff 14 suggestions for a revised mission statement? 15 And is it c6ntdmplated,-- we mentioned the possi- 16 bility of a November meeting -- that it would be debated 17 and discussed by then? Is there any chance we'd get a 18 new mission if we vent that route before the expiration f 19 the present extensions 20 DR. PAHL.@ No, not really. Somehow the 21 discussions got into mission statement when actually what 22 the Department currently is doing is attempting to make a 23 determination as to what programmatic option or options 24 it wishes to pursue with the program over the coming year. 25 Now, there have been a number of suggestions r@A It to R 94 made to the Secretary as to the kinds of activities 2 which the regions can profitably engage in for this one-year 3 r and lperiod, and at his request an options pape subsequent revisions have been transmitted internally. nd 5 lfm-sorry. Because they remain internal, we are not able to 6 distribute them to you. But it is not doing a disservice to 7 that position I believe to state very clearly that all of 8 the options in this internal communication are statements of 9 Activities which the regions have been doing and are 10 very familiar and comfortable v For example, quality assurance activities. 12 Strengthening CHP programs, particularly the (b) agencies 13 Ems. Hypertension. Kidney activities. And the community- 14 based area health consortia. 15 When you hear this, you wonder vbat is different 16 than what we have been doing. And the point is nothing 17 that I know of that is under active consideration by the- 18 Department is different than what ve'holve;been doing. 19 The difference, therefore, is that perhaps one or several of 20 these activities *ill either be specifically excluded 21 from this yearts set of functions or perha-p-s---all o?'them will 22 still be considered permissible by the Department. 23 So it is not the Department or RMPS separating 24 ourselves for the moment -- are trying to devise a different 25 mission statement. It is that the Department feels that . i 95 I with the one -year extension and working in good faith with 2 the congressional intent there is a need during this one-year 3 transition period which begs the question of transition 4 iod the to what -- but during this one-year transition per 5 'Program s should be active in activities Regional Medica 6 uate the RMPs as 'RMPS, yet which themselves do not perpet 7 lengthen administration in Federal health programs 8 or health priorities and perhaps provide a bridge into a 9 new state of affairs after the one-year extension is 10 terminated. that we have been And so the kind of activities 12 asked to suggest for the Department's consideration are tiose 13 1 have mentioned. We believe that there can be useful work 14 done in the areas of emergency medical services, hyper- 15 tension control programs, end-stage kidney disease activi- 16 ties, CHP strengthening, and activity of health planning 17 agencies and certain manpower development and utilization 18 programs and quality assurance programs. 19 And we are awaiting a determination by the 20 Department, which we had hoped to have for you by today 21 but unfortunately we don't,.which then places the Department' 22 stamp on what should be the set of activities for t s one- 23 year period. 24 But I see there is nothing here that is really I 25 a new mission. It is a set of determinations on activities. 96 1 And in that framework the first of the two steps in the 2 telegram was incorporated. Namely, we are awaiting the 3 Department's determination for programmatic direction either 4 to use the $6.9 million which hn-@ in the 5 fiscal 1973 balance or @@ 4"di-CaLto to thp rf%Lyions- v at 7r 6 should be their set of activitip-st ti-tilizinLy fiscal,1974 7 funds, which as yet are going to be at an unknown level 8 and will be determined following the selection of opt ons. 9 And, of,course, this is@@@of great interest to 10 the Coun6il and your roles and prerogatives in the program, DR. ROTH* This gets to the second part of my 12 question, because I have heard of all these figures from 13 $6.9 million, $60 million, $82 million, on up, $159 million, 14 and so on. Being relatively naive about these things, I 15 know that there was this administrative phaseout decree 16 and It was then said that if Congress wanted to pull 17 together an extension law there would be some question as 18 to whether they could get it passed. 19 Well, they did under the circumstances. It was 20 then postulated that it might be vetoed. It was not. 21 But it is still unanswered in my mind. There is one further 22 stop to funds, and that is impoundment or simple failure 23 to release. 24 Now, is this essentially what we don't know the I 25 answer to as y.6t,',whether we are really talking about money 97 1 in hand that you can fund the program with? 2 DR. PAHL.@ I think you are perfectly correct i 3 your observation that there is from our point of Is 4 view as a service an unknown figure, and that is what funds 5 will actually be made available to US. 6 To try to clarify the figures, because it is 7 difficult, the House has recommended through the appropria- 8 tion process a figure of $81.9 million. Since we do not 9 have a full appropriation, we are on a continuing resolu- 10 tion. Under that continuing resolution we certainly, under 11 any objective view of that, would be permitted to go as 12 high as the current operating level, which roughly is $60 13 million. It was, Jerry, $58 14 MR. GARDELL@* $55 million this year. 15 DR. PAHL4. $55 million this year. But the 16 Department has by administrative action determined that 17 it is in the best interests of the program to state initially 18 at this point in time only that all programs, all 53 19 programs, will'be given sufficient funds under the continuing 20 resolution, 1974 resolution, to make Isure that they 21 remain viable through the first quarter of the fiscal year, 22 through September 30th, and we are actively negotiating 23 now through Mr.Gardellts staff with each region to make 24 sure there are sufficient funds that 53 programs will not 25 only be in existence but will have some complement of 98 I professional and supporting staff, space, equipment, and so i 2 forth, through the period Sept6mbei 30th. 3 What we haven't been able to give to the regions 4 is a clear statement as to what kinds of activities they 5 should be engaged in at this point in time or 6 what they will be permitted to do or should be 7 encouraged to do with either the monies that we just 8 distributed at the end of 1973 or any additional funds that 9 come to them through 1974. And that is the status of 10 affairs with respect to the Department's looking at these options. 12 1 hope that clarifies it. 13 DR. ROTH.@ r promise to stop with this one. I 14 given those answers, is it an essentially correct over- 15 simplification of the status of this Council We have 16 got a few options. We could go the route which is at least 17 started with the resolution that staff has circulated to us 18 which says, "We thank you for and approve, retroactively 19 okay, the way you have adapted to a difficult situation." 20 And we could append to this, since we don't know how much 21 money we are talking about, how much we are going to get, 22 that we ought to go along on this basis and trust our staff 23 to do the very best they can with the money available for 24 the best kinds of projects. Thatts one option. 25 The other option is to go in, in rather starry-eyed 99 fashion, with the resolution put in by the coordinators 2 which directs the way money should be spent that we arentt 3 even sure we're going to have, 4 Or we could I presume as a Council go over 5 the whole batch of 53 rograms and pick c 6 thought were good and we would m* e the recommendation for 7 where the money ought@to go4 And that seems totally 8 i 1 in the time frame. 9 But is this about the options up to the Council? 10 DR. PAHL@* Yes. I think I perhaps would-- I find myself in a difficult position. The Council under the 12 authorizing legislation has been established to advise the 13 Secretary on policy for the program, so it seems to me 14 perfectly appropriate, at least with my experience with 15 councils, for this Council to take whatever kind of formal 16 action it wishes, and it could be in the form of a resolution 17 or statement or discussion as to what it views either to be 18 concerns or support of the Administration's current 19 position. 20 We have not been able to bring to you and that 21 may be an administrative failing but we have not been 22 able to bring to you the rapid changes which have occurred, 23 and thus you have not been brought into position in which 24 in fact you could advise us or the Administration about 25 program directions. Today you do hear what the status of 100 I af f airs is. 2 To my knowledge, the determination has not yet 3 been made by the Secretary, although Dr. Laur may be able 4 to comment on that, as to what the Department would 5 1. P- .0,@@e the programs do this I think it is most appropriate, therefore, th@ kind of statement that you would wish to make to me as 8 the Acting Director, to Dr. Laur or certainly to Dr. Edwards 9 or Mr. Weinberger and which we would transmit to the 10 appropriate office -- to make whatever statement you feel 11 is appropriate in exercising your prerogative under the I" 12 and advising us on programmatic directions, options, emphases, priorities that you may see or endorsing your orevious positions. 15 And that's something that',we te I And I think Dri e 16 Teschan was indicating before that a position by the Council 17 perhaps would be of.gkeat assistance to the Secretary. 18 After all, the Secretary and officials below him are that 19 much further removed from the actual program operation 20 and direction that perhaps they would value very highly the 21 advice of this Council. 22 In addition to that, I believe that the question 23 Of the actions taken through the phaseout period and the 24 legality of those actions we have attempted to answer, 25 and I think thatvs a point which I have to leave to the liicn IPS(if 0 t: " vwp @ co "tr 6i 4p so ri Council to decide how it best wishes to handle it. 2 I would like to make one more statement, and that 3 is that in the resolution and if you have not really 4 had time to look at this, and again I am not asking for 5 action at this point -- the resolution which we proposed 6 for your consideration merely would endorse a very limited 7 set of administrative actions that ve.have taken. Namely, 8 the adjustment of budget periods and the adjustment of 9 funding levels on a prorated basis and the adjustment 10 of the Council-recommenaed levels on a prorated basis, which 11 had to be taken in order to carry out what we knew to be 12 your intent and the Administration's intent and the 13 congressional intent, and that is to meet the tests of 14 viability for all of the regions over this period. 15 The resolution that we have proposed for you does 16 not in any way state -- very clearly does not in any way 17 state that the Council has approved those professional 18 judgments concerning either the phaseout of individual 19 RMPs or anything concerning the decisions made relative to 20 which projects, contracts, etc., could or could not be 21 continued. 22 We are in this resolution asking for that ettdorse- i 23 ment only of what had to be done in a technical fashion 24 in order to Arrive at a continuity of the program through 25 the phaseout period and as we go into the fiscal year. 102 So I do want to make that clear, and we as a staff bear the responsibility for the professional judgments 3 which were made throughout this phaseout period of the fA 4 Individual Regional Medical Programs and the activities 5 ',lloved to 00 nn n programs. 6 That is more than you asked for, Dr. Roth, but 7 does this help you in your options for the Council? 8 And perhaps Dr. Laur or Dr. van Hoek, from whom 9 we haven't heard, might care to comment, because they do 10 sit in on some of the meetings that r am not privy to and 11 they may be able to shed some light on this. 12 DR. VAN HOEK: Well, to respond specifically to 13 Dr. Roth's question, it seems to me that there are two 14 parts to the question. One is,the question of retroactive 15 actions, retroactive approval or endorsement of actions 16 that were taken. The other is what happens from today on. 17 And what happens from today on again is two 1 8 parts. One is the immediate question of what do we tell 19 the regions in terms of priorities or program activities 20 that they can carry on during this fiscal year, whether thatts 21 at the use of $6.9 million or some higher figure, and the 22 other part being how can the Council working with the 23 staff develop program statements, justifications for the 24 continuance of the activities beyond this fiscal year 25 in other words, participate in the development of options for IV He 103 legislative proposals. Whether that is a continuation of 2 an RMP in capital letters -- or whether that Is some 3 other substantive program with a different process should be 4 examined. 5 No*, that is not an immediate question. That can 6 be done over the next several months. ]3ut I think it is 7 tied in with the shorter-range issue, because the point-- And 8 as usual telegrams always use the wrong words and give us more 9 problems than we anticipated. But the term mission" I 10 meant to mean the fact that within the existing mission of 11 RMP, through the continuing resolution, that we would 12 identify priorities or specific activities that could be 13 carried out over this next fiscal year which would be of 14 an important nature but would not lead to commitments which 15 would conflict with either legislative proposals or budgetary 16 proposals that would be foEt@VA-inir rivis tbg several 17 months. 18 And so, therefore, that Is really the question. 19 We are really Involved in two processes. One is a 20 legislative process where, despite the continuing resolution, 21 there is nothing on the books that carries it beyond June 30, 22 1974. And then there is the appropriation process which, 23 despite the continuing resolution, means the funding level may, 24 be anywhere from zero to total authorization, depending on 25 what we propose to the Department and to OMB. 104 1 And I really think it's our initiative, as we 2 have done with the options, once the Secretary suggests 3 support of certain approaches and we would like your 4 advice on that it's up to the Department and us then to go 5 to OMB and justify the release of the funds to carry out 6 that activity. 7 DRO PAHL@O Dr. Schreiner. 8 DR. SCMEINER@. I like that analysis. But what 9 bothers me is I have this cartoonist vision of a construction 10 elevator that's been stopped with the motors running on the 11 89th floor pending study to see whether there is enough 12 energy to go higher, and the banker sais, "Well, while we re 13 studying this we're going to cut off the electricity." 14 And itts just innocent, but I think it's incredible 15 that this can be a serious proposal or that this Council can 16 foster standing still for three months. 17 Nov,, there are certain basic activities in the 18 perpetuation of a local resource at the very, very minimum. 19 The electric bill, the salary of the coordinator and the 20 secretary to the coordinator are very, very minimum. 21 Nov, it seems to me completely incredible to 22 say that youtre going to have people who are losing 23 coordinators and losing secretaries hot having the authority 24 to contract for a year to hire somebody for a year to 25 keep this activity going. 105 1 You simply cannot-- I don't hink it's viable 2 to say you are going to go out and recruit somebody for 3 a three-month period. And that's where the rub comes. 4 The rub doesn't co @in in your stud ing the t'hings. The ,me y 5 rub doesn't come in in your vanting,to prune off the barnacles'. 6 The rUL-comes in that the method of going about it is to me 7 a totally inoperable, totalll U!nfeasible -- and so lacking 8 in insight that I don't see how anyone can believe it. 9 Because you end up September 1 with one of two 10 possibilities. You cut the program here, in which case 11 you have wasted three months of funds, or you say we're 12 really going to continue It to the end of the continuing 13 resolution, in which case you have lost a quarter of 14 momentum and you have again wasted three months, so that 15 there is only one activity that can hap n. That is, you Pe 16 are going to waste a quarter's budget in the whole thing, 17 And it seems to me that I agree with Russ, or John, that a resolution is going to get us anywhere but 19 wonder if we can't at least ask for a workshop or a meeting or 20 something concrete to get that three-month business out of 21 the way, because it seems to me that is just so Untenable, 22 given all the circumstances, that I just cantt see how as a 23 Council-- At least I couldn't personally endorse that as 24 a method of operation. 25 - I DR. PAHL.I I think, Dr. Merrill, were you trying t@ 106 get a comment in? 2 DR. MERRILL@. I wanted to point out what I was 3 saying consists of two parts, one of which George talked 4 about, which is the immediate one. But the other one is 5 long-range clout other than simply endorsement of the status 6 quo. 7 This is perhaps something we can talk about this 8 afternoon. But a lot of specific suggestions have been 9 made in the last hour which if put into the form of a resolu- 10 tion would give it some teeth rather than, "Just let's 11 get on with what we're doing." That certainly is the 12 immediate part, but there is something I think which would 13 make RMP durable for a good many years, ot iui--t three 14 months which we might be able to entertain this afternoon lip 15 in specific points, a number of which have been made in the 16 last hour. 17 DR. PAHLI. Mr. Milliken. 18 MR. MILLIKENI. I'd like to ask Mr. Gardell if 19 there is any information in the past or any way to find out 20 in the future that this quarterly funding thing is any 21 different than in the past -- that is, circumstances of not 22 but resolution funding -- or if this is a 23 deliberate intent manufactured for this special situation. i 24 MR. GARDELLI. We have never extended any program 25 in the beginning of a fiscal year for a quarterly period of 107 time, so this is the first time we have done that. 2 Normally, your continuing resolution gives you 3 enough money to be able to get on with the business and to 4 make your first set of awards for the I?-month period, 5 assuming you are going to function on a 12-month period, which 6 is exactly what I said in my presentation. 7 MR. MILLIKEN@. Then it's quarterly? 8 MR. GARDELL@. No, it's not necessarily quarterly. 9 MR. MILLIKEN. Are there any other parts of 10 Government where this has been done b6fore? 11 MR. GARDELL.' There are some programs that fund 12 on a quarterly basis, but I'm not aware of any of a categorica 13 nature. 14 DR. PAHL.I Mrs. Silsbee has a comment. 15 MRS. SILSBEE.@ In answer to your question, Mr. 16 Milliken, I have not been privy to any of the discussions, 17 but I think perhaps itts an understanding of a grant process 18 that may be lacking. 19 1 having made my entire career in trying to 20 develop review procedures that are in line with the under- 2 1 standing of the reviewing groups and the staff, it has 22 been difficult,' and one of the things behind the resolut on 23 we have there is, as you know, we developed a triennial 24 system where regions were looked at and you as Council 25 approved some for three years, and then we had an understandi g 108 of how the review would be accomplished in year 2 and year 3. 2 At the same time you as Council frequently did not 3 recommend triennial funding. You recommended anniversary 4 funding. 5 Well, at this point in time, going back and 6 looking at the review record, we have 13 regions that 7 are in an anniversary situation, and as of this moment six of 8 those really in terms of our understanding should be looked 9 at by the Council. 10 Nov, we're trying to work all of this 11 around because we don't have an application for you 12 to look at. We have got to get this back into some kind 13 of working arrangement between the Council and the staff. 14 We don't know what to tell the regions to apply for. We are 15 in a bind. And in a sense that resolution, which may be- 16 improperly worded, was to try to get you to let us 17 extend until such time as a region can come in with an 18 application. 19 MRS. MMS.I Dr. Pahl, 20 DR. PAHL@. Mrs. Mars. 21 MRS. MARS: -- is there enough program staff left 22 in the majority of the RMPs to be able to carry on effective- 23 ly any major activity7 24 DR. PAHLI. Yes. We have made a survey on that. 25 Mr. Chambliss may wish to respond in more detail. But the I 109 answer is yes. In the majority of the regions that is 2 true. 3 MR. CRAMBLISS@# Yes, there has been a survey, 4 and there is a minimum of staff on board in each of the RMPS, 5 including the coordinators and their secretaries. 6 MRS. MARS.@ That isntt what I asked. I said is 7 there enough program staff left to carry on major activity? 8 Not just coordinator and minimum staff. In the actual 9 programming part of the staff. 10 MR. CHAMBLISSO@ My impression is that there is 11 a minimum of staff that could 12 MRS. MARS*@ Could effectively carry out major 13 activities? @j 14 MR. CRAMBLISS.I Yes. Also our survey has shown 15 that"the regional advisory groups are essentiall intact y 16 and will be ready to respond once they have more knowledge as i 17 to what the real missions of the RMPs will be. 18 DR. PAHL.@ Mr. Hiroto. 19 MR. HIROTOO. I have a couple of questions I i 20 think that have some legal implications. 21 Your definition of the Cqoncills role would 22 indicate to me that if it is merely advisory then this 23 resolution is not necessary for staff, for RMP here, to do 24 what they have done, and so I wonderiif the enabling legisla- 25 tion had a little more meat to it than the fact that the 110 Council was merely advisory in nature. 2 DR. PAHL: The Counbillis advisory in nature 3 relative to the policies, program directions, and so forth. 4 It has a very real function in recommending to the 5 Secretary approval for expenditures of grant funds, and, 6 in fact, the Program Service may not expend grant funds withou 7 the specific recommendation for approval by this Council. 8 So it has a very well defined role in the 9 approval for expenditure of grant funds -- not contract, but 10 grant funds and is advisory in terms of program 11 policies. 12 And it was in the program policy area that the 13 resolution would be advisory. 14 But I believe it is fair to say that all Govern- 15 ment officials take very seriously statements by advisory 16 councils relative to such policy matters. And my own 17 personal opinion is it would be very helpful to know what 18 the Council may feel about these important matters. 19 When it comes to grant funds, the purpose of our 20 resolution and what Mrs. Silsbee was trying to allude to 21 and I don't want to come back to our resolution all the 22 time because It's not really in conflict with what Dr. 23 Teschan.said is that it is giving to us your post-action 24 endorsement of that which we had to do and providing us 25 on of authority in a very limited fashion to continue between Council meetings to do that which actually 2 s ar if regions are to remain viable, which is 3 everyone's intent. 4 And again I think that it Is important to 5 separate then the fiscal actions which@ve have had to take 6 and the authority which we really need from you to take 7 those actions when me don*t have applications or have 8 ceiling levels which are meaningful for regions until such 9 time as we can get back into concert with the recommendations, 10 which we expedt we will be able to do by fall. We are trying to put the brakes on phaseout, 12 stabilize, and move forward -- with serious question marks 13 in this area. But we have certain legal obligations 1A e recognize, one of then being that the sta- not have the authority to continue to support regions and fund them without approval from this Council. 17 On the other h rmlic-atinns to 18 bring to you and no way to advise you and no review conmitteei .9 to recommend ceiling Igavala fivniiincr m, ML 20@ So this is an interim procedure of delegating to 21 us necessary administrative authority. That is what our 22 resolution is intended to do. 23 This does not encompass all, of course, that is 24 in the coordinators' resolution, which is br 25 Dr. Haber? a lb Am 4v ' nfit>CO 112 I DR. RABER.@ I must say I am extremely sympathetic 2 to the position of the staff in this, because there is a 3 basic kind of schizophrenia involved here. On the one 4 hand', as an effective bureaucrat, there is an apparent 5 mandate from the Administration which one must take 6 seriously. On the other hand, there is, as all of you know 7 who are purveyors of health care and interested in the 8 delivery system I think Dr. Laur mentioned it the 9 concern as to what happens to the people out in the regions. 10 One would want to continue certain promising kinds of 1 1 activities. 12 It seems to me that some historical perspective 13 might be useful here, and I'd like to ask the question of 14 you or Dr. van Hoek or Dr. Laur. That is, part of the 15 problem, it seems to me, is due to an evolution of the 16 mission. The Regional Medibal Programs started out to 17 do something somewhat different from what now or laterally 18 appears to be the mission. 19 If one could address that that as heart, cancer 20 and stroke centers some good was accomplished, much good 21 was accomplished in the dissemination of this kind of 22 expertise throughout the system, if@'that could be developed, 23 then I think one might have a clue to what your_ immediate 24 posture might be for the ensuing 12 months. 25 Because then again it seems to me that out of the 113 array of options you chose, one could say, "All right. Tile 2 part of the mission that is available to us for this 3 year is changing. Yet over the course of time RMP has 4 done these following things all under the rubric of 5 disseminating effective health care." 6 And what I'd like to ask is could a case be 7 made that the heart, cancer and stroke centers concept was 8 indeed helped by the RMPs and that the mission evolved into 9 something else which you were not able to complete because 10 the program was caught in mid-flight? 11 DR. PAHL'* Dr. Laur may wish to address the 12 point, because I believe some of the recent meetings he has 13 had entailed those very considerations. 14 Dr. Laur. 15 DR. LAUR: riii try to respond first to that 16 question and then make an observation. To my knowledge, 17 the case cannot be made that heart, stroke and cancer centersi 18 tendered that kind of a positive service. Now, if the i 19 Council can make that case or if the staff can, you know, 20 that would be certainly a starting point. 21 My impression has been that there was considetablei 22 disagreement around the country especially at the local 23 level as to whether those ideas were, in fact, the best 24 way to disseminate improved health care to the people. 25 Nov, I would welcome comment from staff oh that. 114 I But that sort of goes back to the original notion of 2 Dr. DeBakey and the Commission and what finally became 3 law and that finally happened in practice, and I am only 4 trying to read the tea leaves at the bottom of the cup now 5 that we have all@had a deep draught@from,it which says 6 to me that since it didn't happen that way in the real 7 world there was probably something faulty with the idea in 8 at least many parts of America. 9 Now, T would like to have my own understanding 10 broadened if that is not the case. 11 DR. BA13ER*- Well, I am not sure I can make the 12 answer, but t am sure there are people who can make the 13 answer that the dissemination of techniques in care of the @j 14 coronary patient and the education of a great variety of C@7 15 allied health professional people was in some definite measure I 16 attributable to the deployment of the Regional Medical 17 Programs, and maybe the same thing is true in cancer, less 18 so possibly, but certainly in stroke. 19 I think if that case could be made, or At least 20 if the issue could be raised enough so that people could not 21 definitely negate it, I think that would give you a clue 22 as to what the situation might be, what the sition might PO 23 be. 24 DR. LAUR.@ I wonder if I could take a slightly 25 different cut at the same question by saying Ido not believe 115 that this Council or this staff or the people whom you suffer 2 under as administrators of HRA right now can make that 3 case within the time available to make any difference. That 4 goes back to Dr. Merrill's long-range question of! Is that 5 the way we ought to go in@the future? 6 But I thought Dr. Schreiner's question was much 7 more short-run, which vas@. Somebody made what to him 8 doesnft look like themost intelligent decision, which was 9 to fund up to Se tember 30th the core support of RMP so p 10 that they would be around to do some good mission for the 11 remainder of this year while the long-run fat6'gets 12 settled in Congress and in the Administration. 13 Now, it seems to me he had a very specific idea 14 in mind, which was. "Dummies, don't try to do it that way 15 because it wontt work. At least assure core support through 16 the year." 17 That*s a quite different level of decision and 18 recommendation to us than, "Go back to'the centers idea as 19 to the way to get work done. 20 DR.,HABM.@ No, no, permit me. I was trying to s-a4 21 if one could say the mission had been evolving, that part 22 of it could be accomplished, then you have a line on what ul 23 are to do for the next year. 24 Dr. Pahl read for us a list of seven or eight 25 different options. Real case could be made that the accom- 116 plishment could be furthered during the course of the year. 2 1 would agree with Dr. Schreinerts analysis. ltd 3 say dontt lose a quarter of the time. But you could do a 4 great deal towards, say, hypertension control demonstrably 5 in the course of the year, or kidney programs, or 6 DR. LAUR@* Pbrhaps I read much more into your 7 observation than I was entitled to. Every one of the 8 options which we have developed and suggested to the 9 Secretary, the ones you heard, are ones we deliberately 10 picked on the ground that we thought RMPs were superbly equipped to make a major contribution in the time available. 12 Tn other words, we wouldntt have suggested them 13 had we not thought they were appropriate to the mission of 14 RMP and to the health needs of the country and that we 15 had a reasonable chance of getting the money to do those 16 Jobs with. 17 We tried to be quite selective in what we 18 recommended. 19 1was extending your thought to say what we ought 20 to now be doing in the coming year is to establish regional 21 centers for hypertension, which left me less than enthusi- 22 astic. 23 DR. HABER@O If the mission is changing, the 24 agglomeration of these could be subtended on the mission, 25 which would require the cbntinuation,of RMPS. 117 1 DR. PAHL.@ Dr. Ochsner. 2 DR. OCHSNER@* I mould like to speak to the ques- 3 tion of the centers. It seems to me the idea originated by 4 the DeBakey Committee was the centers, but I think they 5 failed miserably in establishing what we have in mind in 6 the RMP, And to go back, they did fail I believe, and 7 thatts the reason why this mechanism was set up. 8 Nov, whether this is the right one or not-- But 9 I don't believe that they did a good job in hypertension 10 and cancer and stroke. They were given a time to do it, 11 and they didn't. 12 DR. LAUR*. From this or other groups I think, 13 Dr. Ochsner, your observation is quite important in the 14 sense that Dr. van Hoek at the end of the table now 15 serves as the Director of the Bureau of Health Services 16 Researdh and Evaluation, and it seems to me after years of 17 exploration we have at least uncovered an important question 18 that ought to be studied by the Federal Government, which is 19 how do you go about accomplishing iins like that? 20 At least we ought to be doing some research on 21 it if not actually moving forward with an action program if 22 we think we have the answers. 23 But what I am trying to separate out today in 24 the remaining hours of your time is: Can you give us 25 advice,which we may or may not follow but I assure you we 118 I will welcome, on@. Given the circumstances right now, what 2 would be the intelligent thing to do, the most useful thing 3 to do? 4 And you suggested some already. 5 1 think we in turn will have to say'. Now,, under 6 the constraints with which we have to work, with the 7 Secretary's office, with the legislative situation, with the 8 Congress, some things can be envisioned and others cannot. 9 What the staff I think is looking for are two 10 kinds of help from you. 11 One is let's put the past behind us, kind of seal 12 it now and be done with that, and give us the kind of 13 guidance you are willing to give us to govern our future 14 actions, recognizing that we will have to take some action 15 before we can get together again and discuss it thoroughly. 16 That is, in the interests of getting on with the job of 17 RMPS, some funding decisions will have to be made between 18 now and September. The sooner the better in our estimation. 19 And we need some guidance from you on how to do that and 20 leave you feeling comfortable with our Actions. 21 1 guess I would add one other point in defense 22 of the September 30 date, since I was inTat least some of 23 the discussionIs. There were really two major concerns. 24 They weren't exactly compatible but that governed that 25 process. 119 I One of them was the view by some of the officials 2 in the Administration that they' were right all along 3 about RMP, that basically it was not fulfilling a 4 worthwhile enough mission to deserve funding and it ought to 5 be phased out. You might come back with a new approach 6 that was okay but RMP was essentially a failure and it 7 ought to be phased out. 8 So that concept is governing some of the 9 kind of decisions that were made. They didn't wish to 10 reverse that decision so they were trying to come up with 11 satisfying the intent of the Congress with the ways of 12 extension legislation without reversing that basic decision. 13 Nov, that's real. It's there. And the staff has 14 to struggle with that. 15 On the other hand, there was another dimension which 16 said, "In reality we want to come up with a useful 17 mission for RMP. We cantt do it overnight. So let's at 18 least get enough money out there to sustain them" -- and 19 here's where they may have made an error in judgement as 20 to what it takes to sustain -- "at least let's get the money 21 out immediately so no RMP will be in dire straits while we 22 get all this straightened out," in the factual circumstances 23 which are that most of the RMPs were carrying out activities 24 into February. 25 You know, December and February were the times in 1201 which under the phaseout plan they were continuing on into 2 those dates. 3 So I think their perception was that not very many 4 people are in dire straits right now and that to avoid 5 a hasty decision that seems to commit the Administration to 6 continuation of RMPs full blast, we'll have this time- 7 limited one. 8 But we picked a time we meaning this is how 9 the conversation went a time was picked which provided 10 what they thought was ample opportunity to come up with an 11 ongoing funding level and a set of HEW expectations of RMP. 12 DR. SCHRETNER@. This is precisely where I find 13 the problem, because if the assessment is that this was 14 a polite gesture by Congress and there is no real intent to 15 go beyond a year., then to@have full funding of the non- 16 programmatic portions is really a waste of the taxpayers 17 money. 18 MR. HIROTO@O I think so too. 19 DR. SCHREINER.; If youtre talking about allowing 20 somebody to recruit a coordinator so that he can extend 21 the existing programs, then somebody has got to be able to 22 recruit a coordinator on the basis that he is going to be 23 here for a year. 24 As I read this telegram, you know, there are 25 vacancies all over the country, but you can't recruit anybody I for more than three months, but he is supposed to then 2 arrange for the extension of programs beyond at least 3 from February to June at the very, very least if you are 4 going to meet the intent of Congress. 5 And so here you are recruiting a guy, you know, 6 and saying he is going to have a job for three months, but 7 his real task is to be sure this program is running well 8 June 30, 1974. 9 And I find that administratively untenable. You 10 either have to decide certain parts of it are going.to 11 be extended for the full year of the extension so that 12 you can carry out the intent of Congress, or you are going 13 to say that the whole thing is impossible and is a gesture, 14 and then you ought to cut it down. 15 What TI'm saying is there are three possibili- 16 ties. Of the three, it seems to me the one you have 17 chosen is the least tenable of the three. 18 DR. PAHL'$ Before continuing this most important 19 discussion -- because this is why we wanted you to assemble on 20 the 17th of July@-- Itd like to come back to some practi- 21 calities. 22 We are very concerned that we have as much dis- 23 cussion and advice from yoult@dday as@ve can possibly derive. 24 1 had indicated earlier that we hoped to be completed by 25 2 o'clock and some of you may have made your plans on that 122 I basis. I should have realized, of course, that, having 2 lived with all of these parameters these many months We 3 thought we could perhaps summarize them more rapidly than 4 we did', and if we took too long we apologize for that. 5 but we felt we had to give you a flavor and a background set 6 of data so that you can go into the considerations of the 7 future a little bit better prepared. 8 So what I would like to ask is what kind of 9 schedule we may look to with you for the rest of the day. 10 If you can stay somewhat longer than 2 o'clock, for example, 11 we could profitably continue this discussion perhaps to 12 1 o'clock or so and break for lunch in the cafeteria, during I 13 which time you could discuss some of these matters which 14 1 dontt think we have gotten quite enough to the point that 15 you feel prepared to propose a position of the Council, 16 and then reconvene. 17 But it we do break for lunch, it is going to be 18 relatively short after we do reconvene, and it may not 19 provide that kind of opportunity for further discussion 20 that both you and we would like. 21 So, as a simple question, is it possible for you to,] 22 stay beyond the 2 o'clock period or do you not wish to 23 break for lunch and vetll try to guide our own conversations 24 here and the other material which I have to present to you 25 which is part of this discussion and which I'd like o 0 123 before we broke for lunch? And I'd like to be guided by 2 what your schedules are. 3 DR. MCPHEDRAN@* How far behind are we in your 4 proposed agenda? 5 DR. pAHL.; I would suspect if we could continue to 6 3 otclock we would have the kind of opportunity that at 7 least I think staff would appreciate havingg but I don't know 8 what that does to your schedules. 9 mRS. MARS.; Three is all right. 10 MRS. MORGAN*. I have a 5 o'clock. 11 DR. RarH.; 4.@30. 12 Dlt. OCHSNER@. I have to leave at 1 o'clock. 13 at 2'30. MR. MILLRKEN: I have to leave 14 DR. PAHLI Why don't we try to stay as much 15 through but terminate definitely,at three. 16 Let me ini6ct one or two things here which I 17 believe should come into the conversation at this point and 18 try to recap not "recap" but give you what I consider to 19 be some important elements which perhaps have gotten lost in 20 all of this general discussion. 21 That Is where do we stand now and what is the 22 staff thinking about in trying to react to all of this? 23 Because I think this should be part of your lunch-table 24 conversation and afternoon thoughts. 25 Facts* We now have 53 Regional Medic 1 Programs, I a 124 all of them guaranteed to be viable through the first quarter 2 of the fiscal year, with a clear intent of the Department I 3 believe to try to make determinations which will permit 4 all 53 to continue throughout the fiscal year with some 5 kind of profitable activity along the set of options that I 6 have indicated. 7 My best information at this point is 8 that there would be a series of options supported by the 9 Department, and, thus, regions would not be confined to 10 doing this or that but that there would be some electivity. 11 The decision has not yet been made. 12 MR. MILLIKEN: Is there readily available by staff 13 a breakdown of this sort of thing now, regional program by 14 program? 15 M* PAHL: A set of what now? 16 MR. miLLrKEN. Identification of existing projects 17 that 18 M. PAHL@. Yes, we have, although not for you today! 19 but wel,db have knowledge on each program as to what activi- 20 ties are being continued and, of course, can derive the 21 latest information Op that. So we can get for you where we 22 stand, but we are not prepared to do that today because of 23 -he time considerations. 24 MR. MILLIKEN: I understand. 25 DR. PAHL@$ However, the set of activities in any 12 5 I one region now going on have already been funded through the 2 phaseout awards that were made. In addition to those 3 activities, in some regions there are no activities going 4 on. They have just discontinued. They have just terminated 5 their last activity. In most regions there are a handful 6 of activities going on, and in some regions there are quite a i 7 few activities going on. 8 Most regions have more than a minimal complement 9 of staff, but it varies dramatically from region to region. 10 Next, $6.9 million has been distributed to 11 the regions at the end of this fiscal year which at 12 the moment they are not permitted to use pending instructions @j 13 from the Department as to purposes for which they may be 14 used. And within those purposes certain criteria must be 15 met. 16 1 want to address myself to that in a moment, 17 because that is the second part of the telegram we 18 haven't talked about which you should be aware 19 of and which we have given much thought to. 20 Thirdly, we are operating under a continuing i 21 resolution, and it is my understanding that as soon as the 22 Department makes a determination as to what the regions 23 may do, we will then develop a spending plan and submit this 24 through the Department to the Office of Management and 25 Budget requesting those funds which would be appropriate to 126 1 the options decided upon by the Department. 2 So I do not know what the spending level is for 3 fiscal 1974. It will not probably be greater than $81.9 4 million, and It probably will be not less than $30 or $40 5 million. 6 This is the result of many conferences and 7 inferences, but we do not know. I donft believe the 8 determination has been made since the options haven't yet 9 been selected. 10 Now, the options that are under considerat on are all those kinds of things which the Regional Medical 12 Programs have been doing. There are no surprises to the 13 Council, and there are no surprises to the coordinators 14 or to the community groups. Thus, it is a question of 15 making decision, not starting off in a new direction for 16 any given Regional Medical Program. 17 Now, let Mfi turn for a moment; to that second 18 stipulation in the telegram, because it is important that you@ 19 understand the thinkin at least that staff has given 9 20 to that cryptic phrase which says, "Regional Medical 21 Programs Service has been authorized to utilize the balance 22 of FY 1973 funds (approximately $6.9 million) with the 23 stipulations that no expenditure be made therefrom until 24 the Department announces the mission of the Regional 25 Medical Programs Service for the remainder of PY 1974 and" 127 now the second stipulation "that proposed RMP activities 2 meet review criteria to be established." 3 What this really says is that the Department has 4 indicated that in expending either the $6.9 million 5 balance from fiscal 1973 -- which has already been 6 distributed in individual awards to the 53 regions but 7 they are not allowed to spend it or in permitting 8 expenditures from the fiscal 1974 funds yet to be made 9 available to the regions, not only will those funds have to 10 be spent in certain programmatic areas now under consideration by the,Department, but within those areas the actual 12 projects which are funded and activities which are engaged in 13 must meet certain review criteria which at this point in time 14 are not developed. 15 So we have an obligation placed upon us by the 16 Department to develop reasonable criteria of a general 17 nature !or those programmatic areas which are approved by 18 the Department and to have these criteria be applied by the 19 local Regional Medi6al Program in consideration of the 20 activities they would like to engage in with either the 21 balance of 1973 funds or the 1974 funds and to have a review 22 process involving you, the Council, and me, the staff, which 23 would certify that the projects are in fact meeting the 24 criteria. 25 And since telegrams cost money, we didn't write 128 all that. We just thought vie would put that all down on 2 July 5. And since July 5 vie have been trying to 3 determine how as a staff we might accommodate these 4 various constraints or, if you will, requirements. 5 In a sense, we are returning from program-,re*iew 6 which you are familiar with with the triennial application i 7 to a modified project review. 8 Nov, I would like to give you the thinking of 9 staff because it does involve both advice from you and 10 hopefully your participation with us over coming 11 months, and the best way I can phrase this I think is to 12 reflect back upon how we managed the earmarks on the emergency 13 medical services funds and also on the community-b ased 14 ANECs where we involved Council in the development of 15 criteria and the subsequent review of these and yet 16 17 had a type of project review back here at the national level, not depending solely on the review process at the local 18 level. 19 What we would propose is in accordance with the 20 Departmentts interest in not waiting until the end of 21 September before regions can get moving, but to provide 22 that kind of framework which will permit regions to move 23 ahead as quickl as the Department decision can be made known y 24 to regions. 25 What We have considered is the following, and I 129 would appreciate it if staff would react or add to what I 2 am about to say because I do want to make it as clear as 3 possible so that we can either get your endorsement or 4 advice as to how to proceed otherwise. And I do mean that. 5 We have given much thought but I am sure there are 6 other ways of doing this. 7 We do expect aDepartmental decision on these 8 various options within a very short period of time. I 9 indicated to you we had hoped to have that decision today, 10 which means v6 may have it this week or next week. I 11 believe we are that close, because I Understand that the 12 Assistant 8ecretary'8 office is in a position to make its 13 recomwndations'to the'SecretAry!s office, whore the final 14 made, so that we hope for a decision very decision will be 15 quickly 16 Once this decision is known, the only thing 17 holding up the regions from, therefore, utilizing the $6.9 18 million that is already out there and from developinga 19 spending plan for 1974 is the fact that we donft have 20 these criteria which the Department believes we should 21 develop and apply against the specific projects to be funded 22 within the constraints or possibilities provided by the 23 Department. 24 So in developing criteria, what we propose to do is 25 to ask the Council if they will with staff and with selected 130 1 vities, coordinators who are closest to these kinds of acti 2 be they hypertension control programs, EMS programs, 3 quality of care and assurance programs, or what have you, 4 to participate with us in the development of these 5 criteria by forming yourselves or with our guidance into 6 Small subcommittees of two or three Council members who 7 could meet possibly in the very first part of September to 8 approve a general set of criteria for the programmatic 9 areas determined by the Department, and to then make 10 these criteria immediately known to the regions, the regions then having the opportunity to immediately provide to 12 as those applications for projects in those areas which, 13 since the criteria are now known to both the region and 14 the Council, would be a simple certification process here 15 to indicate that these Or @jecto can"be approved, approval 16 sent to the regions, and the regions immediately then 17 engage in the kind f staff hirings And initiation of pro- 18 jects or staff service that are requested. 19 We believe that the actual criteria could be 20 developed very quickly over early August and we would hope 21 that in the early September meeting we would make it t littlell 22 bit more clear. The actual applications for specific 23 projects to be funded could come in from the regions. 24 So this would be very much like the EMS and the 25 health services education activity program that we bad 1 about a year ago. 2 This would get regions started immediately with 3 the funds that have been made available. 4 Now, we would believe that if this process 5 were one which you believed would be effective and in which 6 you would participate, we would have to ask that there be 7 an understanding by the Council that these subcommittees 8 had delegated to them the authority of the full Council for 9 making the decisions for the actual award of grant funds 10 either out of the $6.9 million or the 1974 funds for these specific activities without bringing them back to a full 12 Council meeting. 13 Again we are working within a time constraint, but 14 this would get the regions moving in a very definite 15 programmatic direction. 16 It adds an additional layer of review which 17 perhaps everyone would not wish to engage in but which seems 18 to be the appropriate method for proceeding right now. 19 We are open to other suggestions as to how to 20 proceed effectively. 21 We do'belleve that It is not poIssIible to rate 22 in any numerical way the projects that may come in. I may 23 be very mistaken about this. But,6ettainly some kind of 24 ranking in priority order will@be required because we will 25 have to pay on some graded scale, again in accordance with 132 I what may be indicated by the Department to be preferences 2 or even certain levels of funding for certain directions. 3 Nov, that is a modified project review for the 4 immediate future which is merely designed to get the 5 regions moving faster than waiting until September 30th, 6 and we believe, therefore, this could all be done over 7 August-by perhaps one meeting on criteria and one 8 meeting in September of the individual committees, sub- 9 committees, of the Council with staff to review the 10 specific projects that came in. 11 The tote important thing, of course, is to 12 look at the regions as a whole over the fiscal year and 13 the future of this in the longer term, so what I have just 14 proposed is a short-term expedient arrangement to help us all 15 got back into some kind of functioning within the regions. 16 17 The longer-term considerations of each region and the program as a whole would be presented at a November Council 18 meeting where we would have two days, if your schedules 19 permit, to look at all of the regions collectively and 20 individuall and these longer-term considerations as to y 21 what happens beyond June 30th and the kinds of things which v 22 neither have time for now nor are as clear to us as they 23 should be, and over the course of the coming weeks and a few 24 months r believe we will have a better appreciation for what 25 the stands of both the Congress may be and the Administration. 133 1 Now, I just wanted to mention this to you because 2 as a staff we are under an obligation to the Department 3 which is, of course, my problem to somehow release 4 those funds already made available to the region and 5 those funds which can be made avalable to the reg ons provided@ 6 we have criteria and provided projects can be developed 7 which meet such criteria. 8 Now, the kinds of criteria that I am talking 9 about are broad in nature, general in nature, and generally 10 revolve around the idea that whatever project would be II- submitted would be one which would have an impact in a real 12 way in a community over this one-year period. m the Department in any 13 There is no coercion fro 14 a certain line sense of the word to design criteria along 15 or to make things impossible either here or within the 16 regions. The idea Is to use what funds are made 17 available out of the 1973 funds or the 1974 funds to 18 accomplish something in a relatively visible 19 way within the communities over the one-year period but 20 not to start those kinds of activities which would if initiates 21 have to be continued by an RMP as an RMP in order to make an 22 impact in the region. 23 Because, gain, we are probably talking about the 24 continuation of the program in some new form, or alternatively 25 an actual termination, And this from my point of view here I 134 has not been finally determined. But the intentions as I 2 best perceive them are to continue the program in a modified 3 form, the structure of which is at least for me ill- defined but which by November Council meeting may well have 5 much greater opportunity for discussion and useful input 6 from you. 7 If it turns out, of course, that it is 8 1 possible before that time, we most certainly would want your 9 advice. But it is not too helpful today to speculate too 10 lengthily I believe on what happens after next June 30th 11 except perhaps to indicate an overall concern or point of 12 view by the Council. 13 Now, again, that is rather technical, but we have 14 very severe administrative constraints, and we not only 15 need your advice as to how to proceed over the next 60 16 17 days but we from our point of view-- With this recommendatio to you, it would involve your actual participation with 18 staff and with selected coordinators towhee Pi 19 the criteria very quickly and get your approval and then to 20 have possibly a September meeting with the subcommittees, 21 a subcommittee Iprobably established fok'@,d'ach option, a 22 subcommittee for the strengthening of health planning agenc es 23 in the co nity and a subcommittee maybe for the EMS ?mu 24 activity, who could be given the authority by this full 25 Council today to act oh behalf of the full Council and thus 135 to start the regions moving ahead very positively with what 2 funds are available. 3 1 hope I haven't muddied the waters. All of 4 that is contained in those few words of the stipulation 5 No. 2. 6 Dr. Roth. 7 DR. ROTH@. Well, ltd like to react to that. As 8 I look around; I guess I'm the only-one that was on the 9 Council back in the days when we were reaching a decision, 10 which may have been an ill-advised decision, but we 11 always had the dilemma with limited dollars do you put 12 them into places with a demonstrated capacity to use them 13 to put on a good program or do you look at the areas which 14 are backward, deprived, who probably need the kind of stimu- 15 lus that RMP thought it was pre ared to give without p 16 putting on such sophisticated programs? 17 Ouk decision was that indeed we weren't going 18 to deprive the backward, underprivileged areas in 19 order to pour more money into Boston and Philadelphia and 20 places where there was all this capacity. 21 Now, that may have been a wrong decision at the 22 time, and it certainly is a luxury that we cantt afford if 23 we believe that the RMP philosophy is right, that the 24 catalytic role of RMP has demonstrated a capacity to do good 25 in areas, and if we would like in the time available to us I 136 1 and with the funds available to make RMP as visible as 2 hat it v possible, build its credibility and hope t ill 3 attract further funds and congressional and departmental 4 support, it seems to me that this is important, because what 5 has high visibility may be a very rudimentary program in 6 rural Mississippi and what has value in Philadelphia or 7 Boston or metropolitan Washington may be something very 8 different. 9 And I would think that committees would have a 10 terribly hard time looking at 53 regions and coming out with hard and fist criteria of these sorts. 12 It tends to suggest to me that there may be 13 an awful lot ot'vheel-spinning involved in this simply in 14 order to involve Council in a relatively nonmeaningful way. 15 If we are officiating at the demise of a 16 program, you go one way. If we are struggling to save it, 17 you go another. 18 And I believe that the RMP staff as I have 19 observed them in my connection with the program want RMP to 20 survive and believe in it. I have been on enough site 21 visits with them and enough Council meetings with them to 22 know that I think they want it to work. 23 And with the limited number of dollars it seems 24 to me that the only practical thing in this short time 25 period is for the Council to charge staff with picking out, 7 I in the areas which appeal to me that you have listed-- I 2 mean EMS has high visibility, AHEC support may have high 3 visibility. 'These kind of things. And with the money 4 you have got available and geographic distribution the best 5 you can, try to put on a final flare of fireworks, if that's 6 can't be spectacular enoug what it is,'and see i-f,you h with 7 it that Congress and the Department and the Administration 8 will want to continue the program. 9 ltd be willing to consider putting faith in a 10 staff that we have been working with long enough. 11 It's sort of like we have been saying in the 12 regions. You build a good core and then you depend on 13 core to exercise its-judgment on how the available funds 14 should be used. We never redly lot them do that, but there 15 is the opportunity to do that with this central core staff. 16 DR. PAHL@. Well, thank you. 17 Ate there other expressions by Council? 18 We will be breaking for lunch in a moment. 19 Dr. Schreiner? 20 DR. SCHREINER@. I always feel guilty mentioning 21 kidney and hope somebody else will. But I notice it was 22 left out. 23 DR. PAHL@. We had our coffee break. (Laughter) 24 DR. SCHREINER.@ I think if people are going to 25 talk about strengths of the program, even though that came 138 I in very much later than the original heart, cancer, stroke 2 routine, we have got a real talking point in focusing 3 against H. R. 1 where we are going to spend $250 million 4 next year in implementation. 5 Where would this be if there weren't a State- 6 wide program in Wisconsin, for example? Where would this be 1 7 if there weren't a State-vide program in Arkansas? 8 And these were things that were set up by RMP, 9 and I haven't ev.en,beard,them mentioned once, but they are 10 very, very practical points. 11 And I think that ve,obviously ought to continue 12 during this year while we are'intetdig ating with a 9 13 pay program-- There'ts no danger we ate going to have 14 to take over the cost of the patient dare, because it is 15 already taken over. We ought to work on methods for 16 better distribution, better techniques for coordination of 17 programs develop tertiary care centers, all these kind of 18 things. 19 Because our focus is right there in a way that 20 is going to interdigitate with the spending of big dollars. 21 DR. PAHL*@ I thank you for calling my attention 22 to really a very major oversight, because in trying to 23 keep all these points in mind I did fail to say that one of 24 the key options is the kidney option, It's right here in the 25 paper, so you will have to accept the veracity of the 139 I statement. 2 DR. HABER.I You did mention it. 3 MRS. MARSI. You did. 4 DR. PAHL.I it must have been in passing. Let me 5 emphasize it most certainly here. 6 Nov, if we might, since we have until 3 o'clock, uld like to use this as 7 entertain with you whether you vo nsider some of these 8 a point to break for lunch and co 9 matters-- Let me tell you what we see to be at least two 10 necessary items, or three necessary items, of business, 11 all of which I hope are relatively short. 12 one, our own proposed resolution to you, or some 13 variation thereof, is necessary to give us that kind of 14 administrative legality to continue on in the next two 15 months. This is apart from the development of these criteria 16 and the application of the criteria. But adjusting budget 17 periods and so forth. 18 The second thing is there is a resolution we 19 have to hand out to you deal n with the construction 9 20 funds which way back in the early morning were mentioned by 21 Mr. Van Nostrand, and again for us to conduct the Government' 22 business in an expeditious way over the next period until 23 we meet. We will have to take a few minutes and tell you 24 what that is and ask you if you will approve the resolu- 25 tion we are proposing or some variation thereof or else 140 1 we are always going to be answering the telephone to the 2 Congress. But we have to get into that. 3 The third thing is while most of you are still 4 here we would like to have a two-day meeting for November 5 set, although we may have to either adjust that one way or 6 the other depending on circumstances. 7 We believe it would be helpful, and if we 8 may just get that first point out of the way because people 9 may have to leave as we go through the day, I believe 10 there was a calendar provided to you and we'd like to have 11 you look at the month of November. 12 Staff has determined-- Is the 27th a holiday? 13 MR. BAUM: Yes, Thanksgiving is the 27th in red. 14 MRS* MORGAN: The 22nd is Thanksgiving. 15 DR. PAHL.I Does anyone know for the purpose of 16 Government business what 17 DR'. ROTH@. It is Rosh Hashanah. No, I'm sorry. 18 I'm corrected. That's September,?,7tli,, 19 20 MR. PETERSON. According to the Esso calendar the 22nd is Thanksgiving. 21 DR. PAHL$I What we'd like to have you do is look 22 at the week of the 26th the last week of November, and see 23 if we can select a two-day period which is such that 24 most of you tan attend, hopefully all of you but most of 25 you can attend, and at which time we would not only review 141 what had happened, of course, between now and then but look 2 at all of these longer-term questions and bring to you the 3 Departmehtls position, the Congressional position, and so 4 forth. 5 ould be The reason for that is by that time we w 6 able to anticipate formal applications from each region 7 for the total fiscal 1974 funding and you would be 8 acting on those applications for the entire fiscal year, 9 not this piecemeal trying to use the $6.9 million, but 10 if, for example, we are given $40, $45, $50 million for fiscal', 1974, the request for the total fiscal 1974 picture from each 12 region would be in an application which had been reviewed by 13 staff with recommendations to you and that would be part 14 of the business of the Council, together with these 15 longer-term considerations. 16 And there would be staff papers for you and 17 positions that we would hope to give you from the Cohgr6ssion@'I 18 al and Administration point of view. 19 DR. ROTH@* Just a question. Are the five of us 20 whose terms expire still alive for this meeting? 21 DR. PAHL** Youtre alive through November 30th, 22 and it is our hope, of course, with your personal interest 23 and permission, that we will be permitted to extend all terms, 24 and we are looking into the niceties of advisory committee 25 regulations and requirements. 142 1 But we would propose to the Department that it 2 is important for us to have the continuity of your partici- 3 pation, so although the terms do expire November 30th, that 4 meeting would be legal, and beyond that we have to get 5 special action from the Department. 6 We would always be trying to act with filling 7 some vacancies with people knowledgeable about RMP program 8 so we could have as effec,tuve,'fuil complement of the Council 9 as possible. That is a lot to be done in that period. 10 DR. ROTH*@ Then I would propose Monday and uesday,@ the 26th and 27th. 12 MRS. MMS@. Fine. 13 DR. PAHL@. How does that fit with other people's 14 calendars? 15 Fine. All right. The schedule then is for 16 November 26 and 27, Monday and Tuesday, and, of course, we 17 will be in a position I hope to be much more logical about 18 the proceedings than perhaps today. 19 Let us break for lunch, and if we could reconvene 20 perhaps at 2 otclock 21 MRS. MARS4. letts make it before that. 22 DR. PAHL@* letts try to make it quarter of 2. 23 If you have indigestion, it's a result of Council action. 24 (Laughter) 25 So letts try to make it back by quarter of 2 and 143 1 hopefully discussion takes place so that we can get our 2 business out of the way along the lines we have been talking 3 about. 4 (whereupon, at l@.12 p.n., the luncheon recess 5 was taken.) 6 7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23 24 25 144 1 AFTERNOON SESSRON 2 1:50 P.M[ 3 DR. PAHL: Mrs. Mars" informs us that it's five 4 minutes past our lunch hour self-imposed limit. So with 5 that liberty that I have just taken, perhaps we can recon- 6 vene. We have approximately an hour and ten minutes. 7 In thinking about how we may best utilize our 8 time and also feeling that it's important before you take 9 your final actions that Dr. van Hoek have a few minutes 10 to present some matters which he believes you should 11 consider before taking whatever actions you believe are 12 appropriate, I'd like to have Dr. van Hoek present his 13 thoughts to you first. 14 Then, following that, I think we should deal 15 in a businesslike way with at least the resolutions that 16 are in hand and then take up whatever additional points you 17 feel are necessary. 18 So, with that, Bob, would you like to address the 19 Council? 20 DR. VAN HOEK: I just wanted to briefly give you 21 some thoughts based on my experience over the last several 22 years, most recently being involved in both the 23 reorganization task forces And some of the legislative issues 24 that we have been faced with. think they serve as a frame 25 of reference for you to consider both in terms of looking at 145 I some of the options that might be considered and how RMP could'[ 2 impact on those or implement those options As well as any 3 ideas that you might have for the future of the program. 4 There Are several issues that we are currently 5 faced with. As you know, RMP was only one of 12 programs 6 which were to be allowed to expire this fiscal year and which 7 received a one-year extension. Furthermore, along with 8 that extension,' most if no t ill the health manpower 9 legislation which HEW currently administers is scheduled 10 to expire on June 30, 1974. So what we are working on over the next several 12 months in essence is the development of health legislation 13 for virtually everything that we are doing in terms of 14 health manpower and the delivery of health services 15 aside from the financing programs, Medicare and Medicaid. 16 Secondly, as Medicare continues to be expanded 0 17 and Medicaid continues to be evaluated, there are the ques- 18 tions of restructuring those programs, if not looking at 19 the various options of national health insurance. 20 The reorganization is tied in with that, in that 21 the basic concept behind the reorganization was in essence 22 to bring together the various programs or functions that 23 are carried out in the health agencies which in many cases 24 have been separated into separate programs because of the 25 legislative base and the appropriations structure, and the 146 1 reorganization was predicated specifically on the basis 2 of pulling together similar functions and leading probably, 3 undoubtedly, to significant revision of legislation and 4 appropriation structures over the next fiscal year. 5 Now, walking you through a process which we in 6 essence did in part of our reorganization work, if you 7 take a look at some of the functions which are carried 8 out and you look at various programs, the question is asked: 9 What was the basis for that program functioning as a 10 separate entity? And you then have two issues, two 11 primary issues. 12 One is program content. In other words, should 13 the Federal Government be carrying out this program 14 activity or are there significant gaps in which the 15 Federal Government should be involved? 16 And then, secondly, if the Federal Government 17 should be involved, what is the process by which that 18 function or program should be carried out9 19 So you are really facing two issues with RMP. 20 Now, let me point out two separate things. In 21 the reorganization, on the flip chart here, I have 22 diagrammed part of the health agency structure, with the 23 Assistant Secretary for Health having an Office of Policy 24 Analysis and Research. This was the office that Scott 25 Fleming headed until he left In June, now headed by Dan Zwick. 147 And then HRA in which RMP is located, as well 2 as the National Center for Health Services R & D, considered 3 to be the principal agency for carrying out studies, evalua- tion, analyses, data collection, and supporting developmental 5 activities in the delivery of health services. It is the 6 principal R & D agency aside from Biomedical Research, which 7 is NIH, and because of that responsibility it has the 8 primary resources to assist the Office of Policy Analysis 9 and Research which has the responsibility for the Assistant 10 Secretary and for the Secretary of carrying out analyses 11 and the development of health policy in HEW. 12 So that shows you the importance of the location 13 of the RMP program, the RMP staff, as well as other activi- 14 ties in HRA. 15 Now, if you look at the blackboard, what I have 16 done is just quickly sketched -- and this is just in essence 17 a rough example of some of the program content, some 18 examples of program content or functions which have been 19 identified both in looking at the organization of HRA and 20 other programs in the health agencies and also looking at it 21 from the standpoint of where those activities are currently 22 carried out. 23 Now, some of the priorities that were discussed 24 this morning for RMP and which are considered high priority 25 in the Department and in the country as a whole are listed 148 there: 2 Ouality assessment. 3 Standard setting. 4 Health statistics. 5 Planning and resource allocation. 6 Ail of these fufictions@have been identified as 7 key functions that need to be performed and in which the 8 Federal Government has some part to play, whether just by 9 subsidizing community activities or actually conducting 10 some of these in a more direct fashion. I have not completed the second column, but if 12 you take those functions And look at the way HSMHA and 13 other agencies were operating and the way we were structured, 14 virtually every one of the programs in HSMHA, for instance, 15 was carrying out that function in one form or another, with 16 very little coordination, very little joint planning or joint 17 funding. And it was driving HEW, the communities at large, 18 and the regional offices, who were trying to link some of 19 these resource and research activities with the service 20 delivery program, to despair in terms of trying to find out 21 what was going on and *hat information was coming out of all 22 these activities. 23 And I can duplicate that for every one of those 24 functions. 25 In addition, you can also duplicate it in terms 149 of legislation. 2 The question should be asked then in terms of 3 column 3: What is currently on the books which provides the legislative authority and the funds to carry out those 5 functions either in a primary responsibility and then, 6 similarly, secondary responsibilities?' 7 For instance, quality assessment. The primary 8 implementation in the Nation is going to be,through PS 9 But there are a series of other activities related to PSROs 10 which need to be carried out in terms of research and evalua- tion of the effectiveness of PSRO, the development and 12 evaluation of criteria, methods the techniques of 13 quality assessment, and so forth, which are based at the 14 moment primarily in HRA. 15 But here again in terms of quality assessment 16 in PSRO you can identify more than five agencies which have 17 in one way or another had some involvement in the early 18 stages of the PSRO development. And so on through. 19 The question then can be raised: Are there 20 program functions or content which are not being met 21 through any existing legislation or any existing programs 22 which should be carried out? And whether that is carried 23 out in HRA or RMP is one question. 24 Second, if there are gaps that need to be filled, 25 is a program like RMP the most appropriate route to go? 150 1 In other words, what is the content of the program?i I 2 And then what is the process by which you implement it? Is 3 there a need for the Federal Government to subsidize 4 community organizations to carry out the functions that 5 have been carried out by RMP in the past or to carry out some 6 new function in the future? 7 My own reaction in some cases has been that RMP 8 has been used more in addition to a number of the 9 standard functions -- has been used to a great extent in 10 those special initiatives. That is, at some point in time 11 the model cities was a big initiative, so RMPs got 12 involved in model cities. Then there were HMOs two years 13 ago, and EMS one year ago, and so forth. 14 And it relates to Paul Haber's question earlier 15 about the changing mission and priorities'that have 16 occurred over the period of time. 17 And I would like to throw out just one problem that I have identified as the Director of NCHSR&D looking 19 both at quality assessment and the problems of health 20 services delivery. And I think there is a major gap that 21 is not being addressed by any of the health agencies at the 22 present time. 23 And'thitt is methods for studying medical care 24 effectiveness. And by that I mean medical care effectiveness 25 in the Archie Cochran-British sense of the word and In terms 151 of evaluating the effectiveness of medical care in an 2 actual practice setting rather'than,in the research setting 3 where many of the treatment modalities are being tested and 4 evaluated at the present time and again that would link 5 logical, y PSRO, Biomedical Research, and some of the things 6 fbr'which RMPs were originally established. 7 So I just wanted to bring out some of those 8 thoughts that have come up among the staff, and it's not 9 just limited to RMP, but I think it's particularly pertinent 10 to RMP since we are in process of looking at both what if 11 should do this year and what the nature of the program might 12 be in the future. 13 DR. PAHL** Ts there any discussion on the points? 14 These are some of the broader considerations that I think 15 are well to have in a way classified for us, because we 16 will be dealing with them both in the immediate future 1.7 but more importantly in the longer-term considerations. 18 1 don't know whether you have comments now 19 or over the course of the afternoon or-- Dr. Laur, do you 20 have any comments? 21 DR. LATJR: No. 22 DR. PAHL'* Well, if not, I would again thank you 23 and suggest that there are two or three Items of business 24 which perhaps we can address. 25 And because one of them is brand new and doesn't I get into the resolutions from the coordinators and ourselves, 2 1 would like first to treat the construction authority 3 resolution, because it is an isolated point. 4 Ken, would you distribute our proposed resolution 5 to the Council? 6 And if you will bear with me whil,e try to 7 just go through this very briefly as Mr. Van Nostrand 8 indicated this morning, there has been through the legislative 9 process a sum of $17,million authorized for the construction 10 of specified facilities. 11 Although You don@t have to turn to your book, 12 under the tab marked "Quotes" -- in which there is a summary @j 7- 13 of excerpts from the legislative activities that have 14 taken place on the next to the last page -- at the bottom 15 there is a section which deals with the construction 16 authority, and perhaps I should just read it to you. This 17 erpted from the Second Supplemental Appropriations is exc 18 Act, Public Law 93-50, July 1, 1973. 19 "Health Services Planning and Development - For 20 an additional amount for tHealth services planning and 21 development', for carrying out, to the extent not otherwise 22 provided, section 304 and title IX of the Public Health 23 Service Act, $17,000,000, to remain available until expended." 24 That mears that $17 million has been made available 25 in no-year money, so it is not a question of whether the 153 I money will be spent or has to be spent in this fiscal year. 2 It is just a question of how effectively we can discharge 3 the obligation for funding the facilities which were further 4 identified as follows@. 5 In the Senate Report No. 93-160 and also in the 6 floor debate It was indicated that these funds are for the 7 following items:- 8 First, $12 million to permit completion of 9 the new Children's Hospital National Medical Center in Washing 10 ton, D. C. 11 Secondly, $4.5 million to meet the initial needs 12 for a childrents medical center serving the Northwestern 13 regions of the United States. 14 And, thirdly, $500,000 to complete a hospital I 15 in northern Vermont, the North Country Hospital and 16 Health Center at Newport, Vermont, by providing additional 17 grants for hospital construction. 18 Now, in the press of activities, I will have to 19 admit that we have not been able to devote quite as much 20 time to this particular part of the end-of-the-year 21 legislative activities as we would have liked to, and there 22 is some question at least in staff's mind as to what our 23 authorized level of expenditure for construction within the 24 Regional Medical Program Service can be, since under the 25 authorizing legislation we are permitted to spend in one 154 a- I fiscal year no more than $5 million. Yet here in the legisl 2 tion we have a total of $17 million for these three facili- 3 ties. 4 This poses a kind of problem which T have not been 5 able to resolve prior to the Council meeting, and rather 6 ps try to than face it directly T felt I would perha 7 come to you with a resolution which is an innocuous 8 one but will let us proceed once we are able to resolve the 9 legal issue, which perhaps is very simple but which is 10 at least in my mind at this point a little confusing. 11 The second matter Is that it Is quite clear 12 that the funds have been given under section 304 And 13 title TX, and two of the three facilities clearly are within 14 the Regional Medical Program Service responsibility, 15 and those are the North Country Hospital, Newport, Vermont 16 and the Children's Orthopedic Hospital in Seattle, Washington.! 17 What again is not clear, because several authori- 18 ties have been cited in the legislation, is just which 19 program element in the Health Resources Administration 20 is responsible for building or assisting to build 21 the Childrents Hospital in 'Washington, D. C. 22 Consequently, in view of the somewhat uncertain 23 state of affairs from this end of the table relative to 24 this legislation, and hot having had the opportunity to 25 obtain legal opinion on this, we have developed what I think 155 1 is an appropriate resolution for you to consider and 2 hopefully act upon favorably, which I would like to read for 3 the record, And if action is appropriate on it, it would 4 permit us to conduct the business in accordance with 5 whatever is determined by counsel of the Department to be our 6 legal responsibilities and possibilities. 7 So the resolution that've have provided to you 8 states: 9 "WHEREAS the Congress has appropriated $17 million,'! 10 to be available until expended, intended for construction 11 of facilities identified as follows in the Congressional 12 reports: 13 "Childrens Hospital, Washington, D. C. 14 "North Country Hospital, Newport, Vermont 15 ItChildrens Orthopedic Hospital, Seattle, Wash. 16 I'and WHEREAS the construction of such facilities 17 would contribute to the purposes of Title IX through the 18 strengthening of primary care, enhancing the quality and capacity of facilities, strengthening linkages between 20 primary and specialized care, 21 authorized the t'and WHEREAS the Congress has 22 allocation of said funds under Title IX and other authori- 23 ties of the Public Health Service Act, 24 "and WHEREAS the RMP legislation authorizes up 25 to $5 million per year for new construction, 156 1 "the National Advisory Council on Regional 2 Medical Programs, recognizing the clear intent of Congress 3 that construction of the above facilities be assisted, 4 delegates to the Director, Regional Medical Programs Service, 5 the authority to award funds up to the full legal limit under 6 Title IX for that construction determined to be appropriate"-- 7 And I believe the wor should be 8 included, Mr. Baum. 9 MR. BAUM.@ Yes. 10 DR. PAHL@. Following "appropriate," please insert 11 the word "Provided." 12 "1. appropriate application is made therefor; and 13 '2. the applications, plans and specifications 14 meet all HEW and local requirements applicable to the types u c@7 15 of facilities to be constructed. 16 "The Council, further, strongly urges that funds t@ 17 be awarded for construction of said facilities shall be in 18 addition to, and not part of, the total allocation for 19 support of RMPs in Fiscal Year 1974." 20 Again, the purpose of asking you to ta 21 favorable action on this draft resolution is to provide 22 to the staff the authority to proceed within the legal 23 limits of expenditure for those facilities which are 24 determined to be appropriate@for construction under RuMmPr 25 authority as@qui@kly as possible rather than to delay longer 157 since it would not be in the best interests of the communities 2 In some cases the construction Already being underway and 3 the funds being no-year funds, there is no need to delay 4 unnecessarily since the funds in fact will be spent 5 as soon as all of the requirements can be met. 6 Now, I am sorry that I do not have identified 7 for you, therefore, the exact funds that we will spend this 8 year, since it's up to legal determination, and I do not 9 have the knowledge at this point as to whether the RMP 10 program is responsible for Childrenvs Hospital, Washington, 11 D. C., and of course, we will discharge whatever the 12 Department determines to be our responsibility in accordance 13 with congressional intent. 14 MRS. MARS4. I move we accept the resolution-, Mr. 15 Chairman. 16 MRS. MORGAN: Second. 17 DR. SCHREINER: Question. 18 DR. PAHL.I It has been moved and seconded to 19 accept the resolution. Dr. Schreiner? 20 i M. SCHREINER. I don't know whether it's in order 21 but I would like to propose that a slight amendment be 22 made -- that is, that the word e removed 23 and that the word "agrees" be substituted. 24 MRS. MARS'. Where? 25 DR. SCHR91NER: Last paragraph. 158 MR. MILLIKEN: Second. 2 DR. ROTH@. Is there Any possible relationship 3 or parallelism between this and the $15 million of our 4 money they stole for HMOs? 5 DR. PAHL: There is construction authority in 6 the authorizing legislation for RMP, $5 million per year. 7 This has been exercised I believe only once, and that had 8 to do with the Seattle 9 MRS. MARS.' The Hutchinson 10 DR. PAHL.I The Fred Hutchinson Cancer Center. So, to answer your question directly, I believe 12 there is only the palest of coincidences which may appear on 13 the surface. This is a perfectly appropriate expenditure 14 at least up to the $5 million for projects. 15 The identification of these projects, of course, 16 came through the legislative process. So it is not quite 17 in the sense of having an open competition for these 18 funds. And the question, therefore, is not making 19 these available for competition but to assist in the con- 20 §truction of these specific facilities. 21 I don@t believe there is any relationship between 22 the HMO funding of last year and these specific requirements. 23 DR. VAN HOEK4. There was an attempt to put the 24 $12 million in the 304 authority last year and it fell out 25 because of continuing resolution-appropriation problems, but 159 I they did submit an application for funding as a research 2 facility and that application was disapproved. 3 MRS. MARS*@ I accept Dr. Schreinerts amendment. 4 DR. PAHL@O The proposed amendment to the 5 resolution, which has been moved for approval and seconded, 6 is that the phrase "strongly urges" in the last paragraph be 7 replaced by the -- 8 6 The word "agrees." MRS. MARSI 9 DR. PAHL@. -- word "agrees." Is there further 10 discussion on this by the Council? 11 Ah MR. MILLIKEN4. Question. 12 DR. PAHL@. If not, all in favor of the amended 13 ion please say " aye. resolut 14 (Chorus of "ayes. 15 Opposed? 16 (NO response.) 17 It is so ordered. By the way, we, of course, will inform you at an 19 appropriate time what the resolution of these legal issues 20 is and what funding is proposed from the Regional Medidal 21 Programs. 22 I would like to turn now to the resolution 23 vhich,we proposed for your consideration, and without 24 attempting to in any way lessen or bypass the resolution 25 introduced by Dr. Teschan for the coordinators, I would like 160 1 to treat this particular resolution separately, because 2 it does something a little different and it's more limited. 3 And since we have had a chance to look at it 4 again, let me say very clearly that the intent is to both 5 approve A. limited set of administrative actions taken by 6 us, limited to the adjustment of budget periods, the 7 proration, the forward proration, of funding levels and 8 of Council-approved levels for regions, as actions which 9 we had to take in order to accommodate the intent of the 10 Congress and the intent of the Administration until such 11 time as we could have a Council meeting, and, secondly, to 12 delegate to us in this limited fashion that is, 13 adjustment of budget periods and funding level and Council- 14 approved level on a proration basis -- so that we merely 15 prorate those levels over whatever period of time is 16 necessary and whatever sums are necessary in the near :future 17 as necessary until again as a Council we can meet to look 18 and Act on them in the way in at applications from regions 19 which we are accustomed. 20 And at this time that would appear to be the two- 21 day meeting in November, although if that proves to be 22 unnecessarily far in the future with respect to how things 23 go, we may have to be in touch with you and see if we can 24 construct an earlier Council meeting. 25 We are still trying our best to predict how events 161 1 will f low. 2 Mr. Milliken. 3 MR. MILLIKEN*@ Are you ready@for a question? Go 4 ahead if youtre not@. 5 DR. PAHL:- Yes, but I think I will have to read 6 this into the record so we make sure it is there, with your 7 permission. 8 MRS. MARS@. May I just ask are you saying that 9 unless we pass such a resolution your hands are more or 10 less tied? Is that the 11 DR. PAHL*# Yes, itts staff's best impression 12 that we Are skirting Administrative flexibility here. We 13 know we have a Presidential extension of a bill. We know the 14 Council must approve the awarding of grant funds. And 15 we are not quite certain about our schedule of Council 16 meetings and what actually will be necessary until 17 we meet again. 18 So we are asking you to give us that authority 19 of the kind we have already exercised in this limited 20 wa to permit us to conduct the business until such time y 21 as we have applications and a bona fide review and recommended' 22 tions from the Council in terms of new applications. 23 DR. MERRILL@. Doesn't approval of this resolution 24 mean we are in essence approving the-quartetly funding 25 principle as outlined in your telegram? 162 1 DP,. PAHLI. No, it really isn't related to the 2 quarterly funding as such. 3 1 think what we are basically saying is that 4 the quarterly funding which is a departmental-- By the way, 5 ltd like to strike that. That carries an implication which 6 1 think is not really true. All regions are now guaranteed viabil t i@@h irst quarter, but I believe the Department's clear intent is not to fund the program on a quarterly basis. ion merely lets us, depending upon the flay Deco 12 available before we meet again, move ahead to both adjust 13 Council-approved levels and funding levels in order to 14 expend funds in the way in which we mentioned before we 15 may have a full Council meeting and full applications from 1 6 the regions. 17 The problem really has to do with the fact 18 that regions don't have applications waiting on their 19 desks to send to us because we yet don't know what to tell 20 them to construct in the way of program areas and the 21 criteria that I have mentioned. 22 And yet we may have a continuation of fisca 23 1974 continuing resolution funds made available to us which, 24 if we have this authority, we can help regions move ahead 25 functionally without actually having a Council meeting and 163 I incomplete a and we can't see having pplications for you 2 real applications much before perhaps October for staff 3 review and analysis to present to you in November. 4 So this is not really in any way to be interpreted 5 or related to a quarterly funding principle. The staff 6 did not construct it that way. It isn't viewed that 7 way, and it won't be implemented that way. And we could 8 reconstruct it in some fashion if that is the interpretation. 9 But they are separate issues. 10 DR. MERRILLI. I think this statement that you have 1 just made, read into the record, will solve the problem. 12 DR. PAHLio Okay. 13 DR. SCHREINER@. But, Herb as a matter of fact, 14 no RMP that has a vacancy for a coordinator can hire a man 15 on a year's contract even though they have congressional 16 authority to do that. 17 DR. PAHLI. The technicalities are complicated. i 18 What we have said to the Department is that we will guarantee!, 19 the viability of the regions through the first quarter, 20 and by viability I have indicated to Dr. Laur and Dr. 2 1 van Hoek he must accept our professional judgment as to 22 what viability means, and if there is not now a coordinator 23 present, then a region 'Without a coordinator still as of 24 September 3pth would not be considered viable from a 25 prudent managers point of view. 164 And so actually although there is still the 2 schizophrenia and the technical complications, in fact as a 3 staff we are negotiating with regions to have them hire 4 staff, to retain their current staff, and the necessary 5 supporting staff and space and equipment. 6 So that if it is the desire of the region to 7 hire a coordinator, from our point of view that constitutes 8 a reasonable definition of viability to permit that. 9 The question more is whether you can hire a man on the basis of the kind of telegram language that we have had to send out. So it's not that we are restricting 12 the region by not allowing them to hire people. It is that 13 the communications which have gone out dontt make it very 14 reasonable for responsible people to want to take on this 15 until there is some greater sense of stabilization from 16 Washington. 17 And, of course, we are very hopeful very quickly 18 of giving that stabilization. And such things as the 19 resolution that we are considering here would help us 20 implement such a situation. 21 DR. SCHREINERI. We're not trying to give you a 22 hard time, because we really appreciate 23 DR. PAHLO@ I know you do. 24 DR. SCHREINER@. -- your situation. Oh the 25 other hand, I would have great difficulty, because if I *ere 165 I on record voting for that, someone could pick up that paper 2 and say, "What are you beefing about? You okayed it." 3 And it seems to me that it would strengthen your 4 hand maybe if we got specific, if we feel strongly enough, 5 or at least I would feel if I felt strongly enough on that 6 point, to make that as a specific exception, so that there 7 is a clear record. 8 But I'm afraid that, you know, when this 9 gets translated in the newspapers it's going to mean t a 10 the Council is all in favor of this. 11 DR. PAHL@. Well, I think we could certainly 12 and we would be certainly pleased to have incorporated into 13 this document or into another resolution the clear sense of 14 the Council that it does not endorse any principle other 15 than full year funding. 16 Perhaps, Bob, you might like to comment. I'm 17 not sure, because it is a lot of material I have presented 18 on a complicated topic-- Perhaps it would be-- If you had 19 a point to make 20 MR. CHAM13LISS: We do feel, Dr. Schreiner, that 21 this resolution will keep the RMPs alive until such time 22 as 23 DR. SCHREINERI* I understand. 24 MR. CRAMBLISS@. -- there is adequate release of 25 the constraints of the telegram and adequate release of 166 f unds. 2 To answer specifically Mrs. Mars' question, I 3 would say, yes, this does tie out hands unless we do have 4 this kind of authority. 5 DR. SCHREINIM.' We appreciate all that. 6 DR. PAHL@. It's the quarterly funding -- 7 DR. SCHREINER'. How many unfilled positions for 8 permanent coordinators are there? Seven? 9 MR. CHAMBLISS4. We have no unfilled positions. 10 We do have, as I reported earlier, ten acting coordinators. 11 Three of those have been acting for in extend6d period of 12 time, which has been brought to your attention prior to 13 today. There are seven new acting coordinators. 14 DR. SCIMBINER: Has any one of those signed a 15 year"s contrast? 1 6 17 MR. CHAMBLISSI. Fortunately, they come from the I professional staff in the main, and that problem has not 18 i been a very acute one. They are members of the staff who 1 91 have been promoted to the coordinator the acting 20 coordinator slots. 2 1 MRS. MARS: Why don't you just Add a few words 22 in here in this last paragraph as you'd like it. 23 DR. SCHREINER@. Thatts what I think would 24 strengthen you. 25 DR. PAHL: Yes, we would appreciate having that 167 made explicit, because it is the intent to divorce this 2 from any support of a quarterly funding principle. 3 MRS. MARS@* The only thing I don't like about 4 it is this part here where it says "endorses the specified 5 administrative actions taken to date." We never had a chance 6 to endorse them. We were simply told what was going to 7 happen. 8 So we have to accept what has been done, so 9 there is no question about that. 10 MR. CHAMBLISS.@ Well, it can be an ehdorsemen 11 with retroactivity, Mrs. Mars. 12 DR. PAHL: The position is a difficult one MRS. MARS@6 I know you can, but 14 DR. PAHL: -- that we have placed you in. And 15 what we basically are asking is endorsement with understand- 16 ing of the constraints, and, of course, thatts been clear 17 all morning. 18 Put the other way, if you do not endorse these 19 actions, since it is a matter of history one cantt undo 20 the actions, and T prefer to adopt the point of view 1 21 think that Dr. Teschan tried to convey to us, and that is if 22 we can kind of close a door on the past, because it 23 has been difficult on all parties concerned, and move 24 ahead-- And we feel this would help clear the way both 25 psychologically as well as in any legal and program sense 168 that would give us a better basis for moving ahead. 2 But it is placing the Council in a most awkward 3 position. 4t DR. MERRILL: Could one amend this paragraph (4), tl 5 m,'W article (4), so that it reads at the end of the second line the clear un -uancing that funding of programs be undertaken on an annual basis" suredly, yes. 9 Would the Council accept that amended version? 1 0 That would be most supportive of our position. MRS. MARS.@ And with a cleat understanding, 1 2 Dr. Merrill, that DR. MERRILL@. That the programs be funded on an annual basis. 14 15 DR. ROTH@4 I second that. 16 DR. PAHL@. The-suggestion has been.made and 17 seconded to amend the section (4) of the draft resolution 18 with the words added "with the clear understanding that 19 programs be funded on an annual basis," that phrase being 20 inserted at the end of the second line. 2 1 DR. MERRILLI* @And in place of the third line. 22 DR. PAHL@. Yes, and elimination of the third ine. 23 MR. 13AUM: Herb, do you want to read the whole ?@4 thing into the record? 25 DR. PAHLI. All right. Let me ask you, Dr. 169 Merrill, to insert your exact wording, but let me read the 2 entire first part so we have it for the record, if I might. 3 I think it's an important resolution. 4 This would be Council resolution endorsing 5 adjusted bud et periods and approved support levels for RMPs 9 6 and delegating to the Director, RMPS, limited authority for 7 making similar future adjustments. 8 ti(l) WHEREAS@. the President in his budget 9 message to the Congress of January 29, 1973, did not request 10 any further support for RMPs for 1974, thus necessitating that a planned phasing out of both the RMPS and the RMPs be 12 d for the orderly termination of the program, and institute 11(2) WHEREAS: in implementing this phaseout 14 process the RMPS found it necessary to adjust selectively 15 the budget periods of the RMPs and to prorate both their funding and Council-approved ceiling support levels, and 17 "(3) WHEREAS.@ on June 18, 1973, in accordance 18 with the strongly expressed intent of the Congress, the 19 President extended the program for one year, then" -- 20 Section 4. And now, Dr. Merrill, may we have your 21 section? 22 DR-. ERRILL- "(4) BE IT RESOLVED that t 23 National Advisory Council accepts And endorses the 24 specified administrative actions taken to date and, with 25 he clear understanding that the programs would be 170 on an annual basis, delegates to the Director, RMPS," etc. DR. PAHL* All tight. delegates to the Director, RMPS, authority to act in similar fashion as he deems necessary until such time as the Council can review applications from RMPs and determine new support levels for the individual regions." MRS. MARS: That's good. DR. PAHL@. It has been moved and seconded to accept this amended resolution. Is there further discussion MRS. MARS: Question. DR. PAHL4. If not, all in favor please say itaye.11 1.2 (Chorus of "ayes.") Opposed? 14 (No response.) 15 It is so moved. 16 17 Nov, the third matter is one that is on the broader issue and involves I believe the Councilts 18 recommendations -- to accept the resolution or the statement 19 which has been prepared by the Steering Committee for 20 consideration by the Council or to amend It in any way it 21 deems advisable or to take any other such actions as you 22 feel is appropriate under the circumstances. 23 And may I remind you that before we broke for 24 lunch there was a suggestion made which perhaps could 25 either be included in a formal resolution or perhaps discusse@ 171 a little further by the Council, so that there is no mis- understanding as to whether staff will have delegated to it 3 the authority by the Council for the development of 4 criteria and the use of these criteria to award funds 5 either from the fiscal 1973 balance or from fiscal 1974 6 continuing resolution funds for the support of specific 7 regional activities in accordance with whatever program areas 8 are designated by the Secretary for this fiscal year, 9 MRS. MARS: How important is it that cancer, '10 stroke and heart be brought into -- and kidney -- be brought into this criteria? 1,2 DR. PAHL.@ How important? Let me remove the first non obstacle. The 14 kidney is involved. This is a very clearly specified 15 program area which we have every reason to believe will be i(iIsympathetically viewed by the Secretary. t7 There is a hypertension control program option 18 specifically proposed. 19 There is nothing specifically in the cancer or 20 stroke categories, although these could be appropriately 21 included and would be appropriately included in such things 22 as the quality of medical care and the manpower development 23 and utilization categories. 24 MRS. MARS: Because I'm sure you will recall the 25 directive that was given to us that we must turn back towards 172 1 more emphasis on heart, stroke and cancer, and I'm 2 wondering whether this viould influence Congress at all in 3 their thinking and perhaps in furthering and continuing 4 the Regional Medical Program if such emphasis were directed 5 at this time. 6 DR. PABL@. Well, this might be a point of view 7 which the Council may wish to include in a statement 8 which could be forwarded to the Department and may have a 9 bearing. I'm afraid the state of affairs 10 MRS. MARS.@ Do you know what the thinking of 11 the Department is in this? 12 DR. PAHL.' Well, at the moment I think we i,3 feel as staff that we could accommodate all of these 14 activities within the broad options that I have identified '15 for you, although the cancer field is hot singled out, nor 16 is stroke, as a separate area of activity. At-this point 17 the opportunity for further input into the Setretaryts 18 office is limited because of the time that we are working. 19 So the only thing that could be done is to have 20 an expression of the Councilts interest and to the extent 21 possible have this expression of interest implemented within 22 the options selected by the Secretary and with the 23 Secretary's approval. ?@4 MRS. MARS4. I was solely thinking of how this 25 would influence Congress when this came up next year for 173 Irefunding possibly or for reconsideration of continuation of 2 the program. 3 DR. PAHL;. I honestly dontt know, because 4 there are the two points of view that the Regional Medical 5 Programs has in fact done well by broadening beyond the 6 initial categorical disease orientation. At the same time 7 there is a very real interest on the part of individuals and 8 groups to emphasize these areas and less some of the other 9 developments which have occurred in recent years. 10 And I'm not sure I can really speak for how s would really view this, because it's too many Congres people speaking for Congress and I don't have that sense. MRS. MARS; From whence came the directive that 14 we were given by Dr. Stone, if it wasntt Congress, so to 15 speak, or was it Dr. Wilson? Where did that 16 17 come from? We were given a very strong directive. DR. PAHL: Off the record, please. 18 (Discussion off the reco d. 19 DR. PAHL@6 On the record. 20 DII. VAN HOEK4. I think itts fair to point out 21 that the options that we have discussed and presented to 22 Dr. Edwards and presumably are going to the Secretary, 23 although they speak of hypertension and renal disease, are 4 very specific, targeted activities. 25 The renal disease option is Specifically 174 geared to RMN assisting in the implementation of the der Medicare of H. R. I provisions, the support un 3 renal dialysis and transplantation, and hypertension area 4 is specifically targeted not to a broad national program 5 of hypertension And hypertension centers but to supplement 6 the National Heart Institute's program in consumer education, 7 professional education and screening and to assist in 8 organizing community resources to do hypertension screening 9 and treatment. 10 DR. PAEL@ On balance, and being subject to review 11 of the transcri t, I would have to say it Is my best p 12 impression that'-the Departmentts posture at this moment 13 @is to include in this yearts activities, and as a strong 14 consideration for any continued program, certainly emphasis 15 on those categorical disease areas which were the initial development of the program in the legislation, but .17 not by any means to restrict the programs, Regional Medical 18 Programs, or the mission, to those activities, but, rather,, 19 to have them a part of broader areas of activity such as 20 we have been following over the past perhaps two years now. 21 And yet I dontt think I tan honestly say what the 22 Department's final position will be. 23 We will certainly take into account administrative- @-4 ly and also bring to the attention of others whatever the 25 Councills position on this might be. Because this is adv ce. I 175 It is a transition year. And certainly it does bear on 2 vhat the Department and the Congress may think the future 3 of this program could be. 4 So not only now but as we go into other Council 5 meetings and through the year I believe these points of view 6 should be discussed and positions or recommendations made. 7 DR. McPHEDRAN.i Dr. Pahl, I just wanted to ask 8 something about these things that Dr. van -,oek pu up on 9 the board. I'm really asking is it thought that a Federal 10 agency in order to be viable should undertake one or so of these functions? I mean in the reorganization plan? And my further ques ion is@. Isn't it likely that there are going to be some kinds of activities that will 14 have to include all of those? 15 For example, any intelligent medical care plan i(@ would have to include everything on that side (indicating). 17 So that a Regional Medical Program would have to do a 18 of those things really in order to be a Regional Medical 19 Program. And would not they have to have an agency here 20 and again I don't know about that -- but an agency from whom 21 they would get direction in this and who would be their 22 resource here? 23 1 mean is it conceivable that a regional agency 24 that was designed to foster cooperative arrangements between 25 local health agencies and voluntary cooperative physicians, I I 176 and so forth-r- Would not that agency have to have 2 some kind of single central agency like RMPS? 3 I mean if you didn't call it RMPS, wouldn't you 4 have to have that by another name in order to make the 5 concept of an RMP dealing with all of those things on a 6 regional level-- Wouldn't you have to have it? Or could 7 you call it something elOe? Or what -- just in your thinking 8 about reorganization? 9 1 don't think that anybody here maybe I haven't 10 understood it but I don't think anybody here has quarreled seriously with the idea that there is a place for some 12 kind of regional maybe State would be bettor -- but we have all in the past said that maybe the State health agencies 1 4 never could do it properly and that was the reason for 15 starting Regional Medical Programs in the first place -- 16 but that there was real reason for them to get together 17 to help coordinate these activities. @18 And I don't see how those regional agencies 1 9 could ever be expected to do it unless they had 20 some central Federal agency like RMPS to deal with. 2 1 1 dofilt really pretend to understand these 22 things very well, but if you would explain t at to me 23 lfd like to know what your thoughts are. 24 DR. VAN HOEK@* Well, under previous health agency 25 organizations, and particularly under the current proposed 177 1 ones, you can identify a primary responsible agency or 2 organization which deals with each one of those functions. 3 They may be doing that effectively or not, to varying 4 degrees. And they may have varying degrees of 5 Federal funds to carry out that activity. 6 What you're really asking is how at the 7 community level do you integrate the technical resources 8 that come from both Federal agencies and from local 9 agencies and how do you integrate the resources in 10 the community to do an effective Job of planning and 11 operating a delivery system? 12 And the question can be asked@* What is that 13 process in the regions? Is that a Regional Medical Program? 14 Is that a State health authority? Is it, you know, just @15 in essence the laissez faire economic market system? 16 And I think that is one of the problems we 17 are facing right now, why RMP is being looked at, why 18 other legislation is being examined so closely, in that it 19 really deals with a political and social issue in which 1 20 don't think, you know, there is a clear direction for the 21 country as a whole or even at the community level for any 22 particular community. 23 In some areas they are moving toward, you know, 24 State authorities, and so forth, but they are primarily 25 focusing on cost control through certificate of need 178 legislation and rate-setting rather than the overall 2 integration of health services and resources. 3 DR. McPHEDRAN@. Well "Ml am persuaded by Dr 4 Merrill and Dr. Roth that we ought to have, rather than the 5 statement suggested by the coordinators, a statement from 6 this Council that would give at least some new ideas of ours 7 abou"bp fungtion of Regional Medical Pr@rams 8 And I also don't think that I can imagine how-- 9 At least I couldntt write one in ten minutes. I don't 10 think I could write one in ten hours probably. But I 11 wanted to have a chance to think about this. And I 12 guess I want to clear up in,my own mind some of these 13 questions about this particular point. 14 You see, I really think that the idea of the 15 Regional Medical Programs, at least where they vote well 16 functioning, the few I could think of -- I could name them 17 but I won't -- I think the really good ones took 18 into consideration many of those different things. 19 And had they had to deal with that many, as many 20 functions as they worked on, had they had to deal with that 21 many separate agencies here, you know, to get support 22 funds or to get advice, or so forth, I think that they would 23 have been less effective than they were, much loss effective 24 I suspect. 25 And so that I think that having a Regional Medical 179 I Program Service that was really well done, as we have 2 said today -- we weren't just kidding about that,- 3 it was well run on the whole; they got good staff support -- 4 then I think this enabled them to do a great deal of 5 what they did or it facilitated that a lot. 6 @@What it would have been like without that I 7 don't know. Goodness knows. 8 But I think that just as in proper medical 9 care you have to take all those things in consideration -- 10 I mean if youtre any good at all you do all of them or many 11 of them -- so would you in the Regional Medical Programs 12 where you are trying to foster voluntary arrangements 13 between the doctors and hospitals and nursing homes. I 14 think all those things would have to be-- And the medical 15 schools, goodness knows. All those things would have 16 to be taken into consideration. 17 So that I don't think that from what I know about 18 State health authorities-- I dontt think that without 19 being completely done over they could manage that, 20 But I think in the places where it was well 21 done that the Regional Medical Programs at least did 22 that part, and they were the only agencies, it seems to me, 23 that did it. And that's why my special plea is for them. 24 Now, I know that didn't work out everywhere, but 25 that certainly is the way I feel about it. I think that the I 180 1 mechanism ought to be preserved for that region and the 2 hull should be cleaned in places where itts needed, or 3 scrapped if necessary in some places perhaps. 4 DR. PAHL@. Thank you, Dr. McPhedran. I think 5 that is a very eloquent statement about what the 6 Regional Medical Programs and Program Service has been all 7 about, and I don't think certainly we could have phrased 8 it as well. 9 Is there discussion? 10 Time is moving along, and I know your schedules 11 won't permit you to stay much longer, so we would 12 appreciate having whatever kind of thoughts you feel are 13 important. 14 Dr. Schreiner. 15 DR. SCHREINER: Yes. I think it's very 16 important when representing this program to the 17 Secretary's office that you point out that duplication per 18 se is not necessarily immoral or unethical or evil if there 19 is an appropriate rearrangement. 20 Now, you know, everything is fine if you're 21 going into a pure State situation. But where you go to 22 the four corners of Utah or 16 counties around Syracuse,, 23 and so forth,-- And a lot of this program's slow start 24 came because it took us a couple of years sometimes to 25 accumulate the statistics. Not that they verentt duplicative, I 181 you know. They are there in Utah. They are there in 2 Arizona. They are there in the New Mexico Health Department. 3 They are there in the Bureau of Indian Affairs. But nobody is 4 is going to put them together for that natural 5 region except a local entity which looks at it through those 6 eyes. 7 So what is really important is not what is going 8 on with rural New York State or urban New York State but 9 for those 16 counties what is important is that somebody 10 pull together those "duplicate" statistics and rearrange them 11 in a way that makes some regional sense. 12 And this is really what RMP is about. And what 13 'makes it difficult to express is because you can sit back 14 and look at any one of those yellow sheets we used to have 15 and say, "Oh, yes, this piece is there, and this piece 16 is there, and this piece is there," you know. There are 17 the eggs, but there's no omelet unless somebody puts it 18 together. 19 DR. PAHL.I Well, thank you. We perhaps will be 20 calling on you more and more to help us express this in ways 21 which will be meaningful to the Administration and the 22 Congress. 23 Before we move along too much further, is 24 there a consensus by the Council relative to our rather 25 limited field of view at the moment that in the development 182 1 of criteria, which is a departmental requirement, that you 2 delegate to the staff -- and, of course, we will keep you 3 fully informed -- the development and application of 4 these and the authority to award funds on the basis of 5 staff review of applications which meet these requirements, 6 at least until such time as full applications from regions 7 can be bro t to you for review and action? 8 Now, please understand we are not requesting 9 this authority of you. This was my understanding of 10 Dr. Roth's statement as to how perhaps we could move 11 ahead. But I would caution you to understand at this 12 point that if criteria are developed we would do so in 13 conjunction with coordinators and individuals who are very 14 familiar with the program areas under consideration and 15 perhaps would be bringing these at least to your attention 16 for comment before sending them out to the regions, 17 because it is a very important step that would be taken. 18 Because the criteria that would be developed and 19 employed would govern not only the utilization of the 20 $6.9 million from 1973 but would be the same kinds of 21 criteria which would have to govern the use of whate@er 22 spendin@ amount is allowed us !or the entire FY 1974, which 23 could be five, six, seven times that $6.9 million, mm 24 depending on what spending plan is approved by the Department. 25 So we would feel comfortable at least in contacting I 183 those members who would have most interest and 2 ability to comment upon the specific criteria selected 3 even if we didntt formally call you together because we 9 4 do not intend to try to have long hiatuses of no information 5 and then spend most of the day trying to catch you up on 6 matters. 7 But I do want to understand what your feeling 8 is as to whether we are to proceed with your delegation 9 of authority to make awards and inform you of our 10 actions or whether you wish to at least at the time that 11 applications of specific projects may have to be reviewed, 12 approved and funded by staff that you would like to be 13 in on this specific activity in the form of subcommittees as 14 we had announced earlL3ier- 15 Itts a very important point for staff 16 because we dontt want to get back into the ptocess'whe'rel,".@ve 17 are through expediency bypassing you without, of course, 18 your full knowledge and endorsement to be bypassed. 19 MRS. MARS@. I think we should certainly permit 20 staff to make the awards as necessary. Certainly it's 21 our vote of confidence in you, and surely your knowledge is 22 such that it would be far greater than ours could possibly 23 be. 24 think that some of the criteria though I do 25 that it should be based on the fact that the programs that I 184 are accepted for funding are those which certainly 2 will do the greatest good in the shortest time, and also 3 with the thought behind them that they will be programs 4 that can be so effective and so essential to a community 5 that a community will be willing to pick them up and go 6 on m, or some other organization such as the 7 State itself continue with them. 8 1 think that probably would be one of the 9 bases of the criteria that I would suggest. 10 DR. PARL@. Thank you. That is a very important 11 kind of consideration which we too had felt would be the 12 type of criteria that we would wish to develop. 13 Dr. Roth. 14 DR. ROTH@. Herb, does it throw any said in the 15 gears to include in that -- I agree with everything Mrs. 16 Mars has said but would it in any way vitiate the intent 17 to add the words, "It shall be the intent of this Council 18 to authorize staff to proceed consistent with the 19 existing mission statements achieved by the Council"? 20 The coordinators have asked for this, and I tend 21 to agree that we have worried this mission concept maybe 22 unduly, and it may have been an unfortunate word in the 23 telegram, but wouldn't that clarify thinLra? 24 DR. PAHL: Yes, I believe there is nothing 25 that is being discussed within the Department or the 185 1 Service which detracts from the mission statement which the 2 Council endorsed for the program some time back. And what 3 we have been talking about is a set of programmatic 4 activities within that broad mission statement. 5 And from what I have tried to indicate to you as 6 well as I can, it is my belief that the Department will, 7 in fact, provide the regions with the opportunity to 8 engage in activities of the kinds that we are all familiar 9 and comfortable with within that broad mission statement 10 that we still are living by and which the coordinators wish 11 us to live by and which you have just indicated should be 12 our reference point. 13 So I think the record can show that we are 14 working within that mission statement for this fisca year, 15 and during the course of this year we all will be,concerned 16 with the longek-term directions and organizational structur 17 and processes. 18 DR. ROTHI* If the staff would appropriately 19 word a statement which 20 MRS. MARS;. Right. 21 DR. ROTH4& would clearly say that the 22 Council authorizes staff to proceed consistent with the 23 existing mission statement and according to criteria 24 properly and appropriately adjusted to the regional 25 Situations in order to achieve greatest visibility and QT 186 project the program in the best possible light, I would so 2 move. 3 MRS. MARS.@ I'll s 4 DR. PAHL. All right. It has been moved and 5 seconded for staff to develop this statement. And may 1, 6 because I believe this is an important step by the Council 7 and one that we will feel most comfortable with if we 8 can make sure that our words do reflect accurately-- If 9 we could perhaps take the statement which we develop and 10 come back-- And let me just suggest that we do this by 11 telephone. We are doing a lot of things in order to move 12 ahead. But v6 can have this as a matter of record 13 that you as a Council individually will approve or we will 14 so see to it that our words do in fact convey this for the 15 record, because we are working within departmental and 16 congressional intents, and at times the cross-currents are 17 difficult, and we would like to make sure that we have 18 that. But we know how to act and proceed and will be in 19 touch with you. 20 DR. MERRILL#I Are we talking about a separate 21 statement now simply for your purposes? This has 22 nothing to do with the coordinators? 23 DR. PAHL,.; No, vetre talking about a separate 24 statement for our purposes. We will develop it and get 25 your 187 1 Because DR. MERRILL: there is a second paragraph 2 to which I object in what is in the coordinators state- 3 ment which sounds vaguely like that. 4 DR. PAHL@. The coordinators' statement is open 5 for whatever action the Council wishes. It can be 6 accepted as a reflection of the coordinators' interest and 7 concern or it can be acted upon in any way in whole or in 8 part I'm sure, and that is a matter for you following Dr. 9 Teschan's discussion. 10 MRS. MARS: Well, I think really we can table It 11 for the moment. 12 MRS. MORGAN@. I move that we table this to our 13 next Council meeting. 14 DR. PAHL.@ All right. It has MRS. MARS: And let them perhaps come back with 16 a revised statement or something, I dontt think this is 17 acceptable. 18 DR. PAHL@. Staff will inform Dr. Teschan that 19 the Council has received this statement, has tabled 20 it for consideration at the next meeting of the Council, 21 and that we will advise them that should they care to 22 revise and resubmit it -- 23 DR. MERRILL@. Could we also give them some 24 direction in how we think it ought to be revised? 25 DR. PAHL.' Yes indeed. 188 1 DR. mERRiLL.@ Because I think these first 2 two paragraphs are really, as I said several times, kind 3 of a slap on the wrist and a blow for the status quo 4 and would be totally unacceptable to any administrator after 5 a long, hard day. And if one could stress positive 6 aspects of what we intend to do rather than these negative 7 ones 8 DR. PAHL@* Well, we Vill take the full record of 9 the Council 10 DR. MERRILL: I think in the discussion we have 11 had here there are all the points I would like to make. 12 They can be pulled out. 13 DR. PAHL@4 That will be done and we will 14 transmit as full information as possible to Dr. Teschan. 15 MRS. MORGAN@. Don't you feel in these criter a 16 that we have said for staff to come up with where t re 17 is input Council in establishing it this will be 18 something than Muld also alleviate a lot of the problems 19 here? 20 DR. PAHL@* Yes, it would. 21 As we just close 22 MR. BAUM.@ Before you close, I have something 1 23 would like to clarify for the record. As one who has 24 to write the official record, let me see if I have this 25 straight. I 189 1 The proposed resolution presented by Dr. Teschan 2 this morning is tabled for further consideration next 3 time with certain advice to be delivered as to where the 4 wording can be strengthened. In the meantime I gather that 5 we have a-- I don't know whether itts a motion or 6 we voted on it or just what by Dr. Roth that we as 7 staff develop a statement which would reflect those things 8 which were put on the table by Mrs. Mars, Dr. McPhedran, 9 Dr. Roth, and others in the afternoon discussion indicating 10 the general intent of the Council with respect to the 11 delegations that were ap .proved and that we check t 12 wording out with you by phone or some other communication 13 before we write it into the minutes of the meeting. Is 14 that correct! 15 MRS. MARS: It was seconded but I don't think we 16 voted on it. 17 MR. BAUM@6 Do we need a vote on that? 18 DR. PAHL: Well, to make it official, all 19 in approval of that description of our action please say 20 aye. 21 (Chorus of "ayes.") 22 Opposed? 23 (No response.) 24 Itts carried. 25 DR. RURH@. My thought was if -We@hitd to go 190 1 retroactively and approve something that we hadn't 2 approved before, I would rather give you approval now. 3 DR. PAHLO@ All right. Okay. Well, we appreciate 4 that vote of confidence. 5 Before we adJourn -- 30 seconds -- one, I would 6 like to indicate to you the CHP Council has not only an 7 interest in but the requirement for a liaison member from 8 our Council, and Dr. Watkins has been our selection, and 9 he has very graciously consented to represent this Council 10 on the Comprehensive Health Planning Council. I believe 11 that first meeting is in September, but we will be 12 getting information to you. And at Council meetings 13 we would look forward to having reports from you about the 14 activities of that service. 15 Also I again have been remiss in noting our 16 pleasure at an event that you all are very well aware of. 17 That is, Dr. Roth's presidency of the American Medical 18 Association. And I'm afraid my own limited set of problems 19 made me overlook that announcement earlier today. 20 Is there any other business? 21 (NO response.) 22 Almost all of our public members have left, 23 but if there is any public participation this is the last 24 closing moment that one has. 25 (No response.) 191 1 If not, I would like to thank all of you for 2 a very long day and for trying to absorb a 3 tremendous amount of detailed technical material, for your 4 understanding , both personally and officially, in your 5 capacity as Council members, and to say that from this point 6 on we really do look forward to keeping you informed, and 7 we have set up arrangements to do that, so that we will 8 not try to burden you with things but to keep you abreast of 9 high points as we go through still a somewhat complicated 10 year concerning the technical matters internally but giving 11 you points of view from the Administration, the 12 reorganization, the congressional intent, and, of course, 13 our activities relative to the regions. 14 And again thank you for a very understanding 15 Council and full day. 16 The meeting stands adjourned. 17 (Whereupono at 3:-07 p.m., the meeting was 18 adjourned.) 19 20 21 22 23 24 25